Efforts to reduce chronic school absenteeism are shining new light on the prevalence of illnesses like asthma among students and the lack of trained medical professionals stationed in Hawaii schools.

Hawaii currently lags behind most states when it comes to the availability of school nurses.

Federal guidelines recommend one trained nurse for every 750 students. At the start of the 2013-14 school year, the Hawaii Department of Education had three nurses on staff for 180,000 students.

At most schools in the state, everything from scrapes to colds are handled by school health aides, who consult with Department of Health nurses for advice on more serious problems.

But research shows that students under the supervision of a health aide are three times more likely to get sent home for an ailment than students at a campus with a registered nurse, said Mary Boland, dean of the University of Hawaii’s nursing school.

Leighton K. Kaonohi, PA-C, checks blood pressure of Nihoa K. Kaonohi at the Ko'olauloa Health Center at Kahuku Intermediate and High School.  2.21.14 ©PF Bentley/Civil Beat

Leighton K. Kaonohi (shown here in 2014 at Kahuku High & Intermediate School) examines a student at the school health clinic.

PF Bentley/Civil Beat

That’s in part because the health aides often have no medical training beyond first aid and CPR certifications, so students in need of medication like an asthma inhaler often have to be sent home for the day.

School administrators and healthcare providers are hoping to change that soon, through new partnerships and pilot programs aimed at increasing the number of nurses working with schools, streamlining the process for allowing students to administer their own medication, and providing free medical training to all health aides in the state by 2018.

Truly meeting the health needs of students will also require big community efforts and broader policy changes in the state, doctors say.

Increasing the Number of Nurses

Historically, school health in Hawaii was the responsibility of the Department of Health, though in recent years it’s become increasingly a collaborative effort.

School health aides work for the Department of Education, but the DOH still writes the manual for school aides and provides annual training in things like how to administer an EpiPen for students having a severe allergic reaction.

Additionally, the DOH has 87 public health nurses, who provide school consultations and services on a part-time basis.

State efforts to increase the number of dedicated school nurses are being led by Hawaii Keiki: Healthy and Ready to Learn, a new partnership between the DOE and UH’s School of Nursing and Dental Hygiene.

The collaboration grew out of the district’s federal Race to the Top grant process, said Camille Masutomi, who works on community engagement and partnerships in the superintendent’s office.

“The number one request from both the community and school side was to address attendance issues,” Masutomi said. “And all our attendance issues in one way or another stemmed from health issues.”

The program started out small this year, with four nurses placed in schools throughout the state, but the goal eventually is to have a registered nurse in each of the state’s 15 complex areas.

“We know some schools like the big high schools could have two nurses, but we are not at that point,” Boland said.

This year the Hawaii Keiki nurses, who are currently paid by the DOE, are working to improve school attendance by more aggressively monitoring and treating illnesses.

They’ve also been reviewing school health records, surveying parents to see what their needs are, and working with the DOH to build partnerships with local healthcare providers to screen students for vision and hearing problems.

“Probably two thirds of absenteeism is caused by health problems, but we also know we can’t just pull millions of dollars out of the air to have nurses in every school.” — Mary Boland, UH Nursing School dean

By being in schools, the nurses have been able to complete need assessments and get very specific data on community health challenges, Masutomi said.

The most common issue is asthma, but every community has other varied problems.

“You think you know an issue, but until you have the raw data you really don’t,” Masutomi said. “Now I can go to the state Legislature and say, ‘My health aides are faced with all these issues.'”

It’s been enough of a success so far for lawmakers to approve $1 million in funding for each of the next two school years to help pay for extra nurses. In 2016-17, the program will have to come up $500,000 in funding on its own.

“Probably two thirds of absenteeism is caused by health problems, but we also know we can’t just pull millions of dollars out of the air to have nurses in every school,” Boland said.

For now, Boland said, the goal is to expand the number of nurses in a way that is sustainable. One idea for that Boland said, is to try and get changes to the state’s Medicaid plan to allow the DOE to bill for services provided on campuses.

If approved, the nurses could administer immunizations, treat students for minor emergencies like sprained ankles and provide case management — all medical services that a doctor’s office could bill Medicaid for.

“We are doing (the program) in the context of changes that are happening in the field of healthcare,” Boland said. “Such as having interventions when patients are healthy instead of waiting until people are already sick.”

New training efforts for school health aides could also help with the breadth of services offered at schools.

Kapiolani Community College created a 75-hour course for school health aides that it launched last year. The free course will be offered at additional community colleges in coming semesters, with the goal of getting all 255 health aides in the state to take the training by 2018.

And allowing school nurses or health aides to administer daily medications at school for chronic illnesses like asthma could significantly reduce absenteeism, said Dr. May Okihiro of the Waianae Coast Comprehensive Health Center.

Asthma is one of the most prevalent chronic illnesses in the state, with as many as one in four children in some areas reporting an asthma diagnosis.

“It’s about seeing how we can get healthcare infrastructure into places where the kids are, so they can stay in school,” Okihiro said.

High Asthma Rates

One of the schools hosting a Hawaii Keiki nurse this year is Nanaikapono Elementary in Waianae, where roughly a third of the school’s 890 children reported having a chronic illness at the start of the last school year, with one in four children suffering from asthma.


Marina Riker


In 2012-13, 41 percent of students missed enough school days to be deemed chronically absent, Principal Debra Knight said.

Statewide, 18.9 percent of children are diagnosed with asthma at some point during childhood, with roughly 12 percent to 13 percent of children actively dealing with asthma in any given year.

Genetics, geography and poverty all play a role in the high rates of asthma prevalence. There may be other issues that impact specific communities though.

Okihiro is hoping to get a federal grant later this year to study why kids in the area have such a big problem with asthma, but also what can be done to treat their asthma in a way that keeps them in the classroom.

Okihiro should find out in August if the application for a one-year planning grant is approved. The next step after that would be a five-year study on asthma causes and prevention.

In particular, Okihiro wants to find out if schools can see an improvement in attendance and student health if nurses or health aides administered daily controller medications to certain asthmatic children.

In the meantime, one significant challenge for asthmatics that Okihiro and Hawaii Keiki nurse Makana Prothero have identified is access to emergency asthma inhalers at school.

Because school health aides aren’t qualified to diagnose the severity of an asthma attack, if a child has to use an inhaler and doesn’t have prior approval on file, the school health aide has to call the child’s parents and send them home for the day.

The result, Okihiro said, is that some parents simply don’t send their children to school if they have a cold or allergies that are likely to trigger an asthma attack.

“If we want our kids to be on safe on campus and have these plans, we have to make it easier.” — Hawaii Keiki nurse Makana Prothero

Other parents tell their children to take their medication in a bathroom stall or another discrete place where they won’t be noticed.

To give approval for the school to store and administer emergency medicine to children — or for a child to be able to carry and take their own — parents first have to get their doctor to sign off on a form. Then the school has to send that form to a DOH public health nurse who has to write a consultation report. Then the school has to hold a meeting with the parent, student and teachers to go over the plan, Prothero said.

This year, Nanaikapono Elementary had 10 Emergency Action Plans for students with asthma and an additional six students with approval to carry and administer their own asthma medication.

Simplifying the process is a top priority of nurses, Prothero said.

“If we want our kids to be on safe on campus and have these plans, we have to make it easier,” Prothero said.

Doctors at the Waianae Coast Comprehensive Center are also looking at working with the DOE to identify more ways to keep asthmatic children in school, Okihiro said.

The increased collaboration between the various departments and community health providers is a good thing, said DOH Public Health Nursing Branch Chief Joan Takamori. But parents also need to have a stronger voice in addressing campus health concerns.

“I am open to ideas,”  Takamori said. “I know the system doesn’t work perfectly now and we want to improve it. There are a lot of challenges for parents and we want to work on it.”

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