The Journal of School Nursing
2021, Vol. 37(1) 61-68
© The Author(s) 2020
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DOI: 10.1177/1059840520974346
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Mayumi A. Willgerodt, PhD, MPH, RN, FAAN, FNASN , Elaine Walsh, PhD, RN, PMHCNS-BC, FAAN, and Caitlin Maloy, MLIS
The Whole School, Whole Community, Whole Child (WSCC) model is a student-centered approach that focuses on a culture of health to support student success. Despite its use, the empirical evidence supporting the model is unclear. We conducted a scoping review to understand the research supporting WSCC as a model for student/school health. The search included studies published in English language peer-reviewed journals from 2014 to 2020. Eight articles met criteria for review. Overall, findings from this review reveal a relatively small body of research specific to the WSCC model. Because WSCC is presented as a model for schools throughout the United States, the development of a larger body of research supporting the model as an evidence-based framework will enhance credibility and confidence in the model. School nurses, as leaders, coordinators, and advocates, are well positioned to test and disseminate the model to those seeking to introduce WSCC in their school or district.
Whole School, Whole Community, Whole Child, school nursing, school health, scoping review
Introduced in 2014, the Whole School, Whole Community, Whole Child (WSCC) model is a student-centered and community-grounded approach that emphasizes collaboration and coordination of programs across multiple sectors within the school and community to promote a culture of health that supports student success (Association for Supervision and Curriculum Development [ASCD] and Centers for Disease Control and Prevention [CDC], 2014). The Framework for 21st-Century School Nursing Practice, which articulates the roles, skills, and activities of school nurses, is in direct alignment with the WSCC model, demonstrating that school nurses are well positioned to lead and coordinate implementation and evaluation of WSCC (National Association of School Nurses, 2016). In fact, the National Association of School Nurses (2017) recently published a position statement recommending that all school nurses be knowledgeable about WSCC.
Despite the widespread use of the WSCC model, evidence to support its effectiveness is limited. Existing data document the association between various specific programs that align with individual components of WSCC and student health and/or academic outcomes (Michael et al., 2015). It is unclear, however, the degree to which research has been conducted that either uses the WSCC model as a conceptual framework or examines the model in its entirety. Understanding the empirical evidence surrounding WSCC is critical to validating the model and guiding school nurses’ collaborations with families, schools, and communities to promote child health. In this article, we report on findings from a scoping review of WSCC to understand the research evidence supporting WSCC as a model for student health that exists in the peer-reviewed published literature.
The WSCC model was developed in 2014 through a partnership between the ASCD and CDC (2014). The WSCC model represents an evolution of the Coordinated School Health (CSH) and Whole Child (WC) initiatives, which provided a framework for schools to create infrastructure and implement policies in a coordinated fashion to support school health and academic success (Lewallen et al., 2015). Comprised of eight components, the CSH model adopted more of a health perspective, while the WC model was more grounded in an education perspective (Lewallen et al., 2015; Rasberry et al., 2015). The WSCC model built upon the work of the CSH and WC models to proffer an ecologically based framework that integrates the two perspectives and encourages interprofessional collaboration across multiple sectors to promote child wellness.
The WSCC model is holistic and comprised of 10 components that impact health and academic success (ASCD & CDC, 2014; see Figure 1). The model highlights the importance of families and communities in supporting schools to create a culture of health, engaging with students to shape their educational experience, and supporting collaborative communication among individuals addressing each model component to reduce redundancies and maximize efficiencies. The ASCD and CDC identified strategies specific to each of the 10 components and provided exemplars of integrating services across the WSCC framework (National Association of Chronic Disease Directors, 2017). Since 2014, the WSCC model has been implemented in a variety of ways in schools across the country and is “visible” in numerous venues (Collaboratory on School and Child Health, n.d.; Moyer et al., 2016). It has been used by schools and districts to guide the development of policies and procedures and to support individual programming within and across schools (Chiang et al., 2015). However, empirical data that support WSCC as a model are mixed. WSSC was developed via expert opinion and therefore is a solid and logical framework. However, models that are validated by empirical evidence are more likely to be adopted, and schools/districts are often motivated, or even mandated, to use evidence-based programs. In addition to providing guidance, models can provide standards of care and benchmarks for success, which must be grounded in evidence. The peer review process allows for objective assessment of one’s work, and this assessment by outsiders who are not invested in the outcome of the work can provide validation and endorsement of a model, thereby enhancing its utility in practice. Additionally, peer-reviewed literature is more likely to be viewed and valued by academicians who are responsible for determining components of the curriculum in health sciences programs. This can increase the likelihood that the WSCC is taught and used as a framework for interventions by students and professionals entering the workforce. The WSCC framework has a presence in the gray literature; however, gray literature is self-published and not subject to peer review. This evidence is certainly valuable, but providing empirical evidence of the WSCC model that has been vetted through peer-reviewed avenues is critical to ensure its validity and strengthen its credibility. The peer review process is essential to the advancement of science (Lee & Moher, 2017; Siegel, 2008).
We undertook a systematic scoping review to describe the current body of research on the WSCC model and identify gaps and opportunities for future research. Scoping reviews are indicated when there is a need to:
Scoping reviews are also indicated when “feasibility is a concern—either because the potentially relevant literature is thought to be especially vast and diverse (varying by method, theoretical orientation, or discipline) or there is suspicion that not enough literature exists” (Canadian Institutes of Health Research: Knowledge Translation [http://www.cihr-irsc.gc.ca/e/29418.html and www.cihr-irsc.gc.ca/e/29418.html] in Levac et al., 2010). Therefore, this scoping review was undertaken to address the following two aims: (1) to describe the scope of research that uses or tests the WSCC model and (2) to identify opportunities for future research.
This scoping review was guided methodologically by an adaptation of the Arksey and O’Malley Framework (Levac et al., 2010). Reporting guidelines by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) informed the development of this article (Moher et al., 2009). In this article, we describe and examine the body of published peer-reviewed research related to the WSCC model. We conclude with recommendations for future research directions.
The WSSC model was formally introduced in 2014 and thus served as an anchor for our literature search. Additionally, since we were interested in published work that has been subject to review before publication, our search included all articles published in English language peer-reviewed journals from January 2014 to May 2020.
Our information sources included Academic Search Complete, CINAHL Complete, ERIC, Medline, and PsycINFO as part of a larger EBSCO search. In addition, we searched PubMed, Scopus, Web of Science, and Embase. Because the focus of our review was to understand what has been published using the WSCC model specifically and because we wanted to capture as many studies as possible, we intentionally searched for the WSCC model by name and included potential alternatives for the name to locate any study that referenced this model. We used “Whole School, Whole Community, Whole Child” and “Whole School Whole Community Whole Child” as search terms, accounting for potential variations in punctuation choices. Searching for the WSCC model by name eliminated unrelated studies and irrelevant models from our search results. We limited the results to “scholarly (peer-reviewed) journals” or “academic journals” and those published in English between 2014 and 2020.
A three-step process was applied to determine an article’s eligibility for inclusion in this scoping review. First, all article titles and abstracts were entered into the original database and manually reviewed for relevance. Full-text articles that mentioned WSCC in the title, abstract, or keywords or referenced WSCC as a conceptual model were placed in a secondary database. Articles that did not mention WSCC, only included WSCC in the reference list, or reported on research or experiences outside of the United States were eliminated. Second, 10% of the articles (n = 25) in the original database were randomly selected for review by the second author to validate inclusion or exclusion decisions made by the first author. There was 100% agreement. Third, all full-text articles in the secondary database were reviewed by the first and second authors to determine final inclusion in the scoping review.
All articles were independently reviewed by the first and second authors to determine whether the article constituted research or not. Results were compared and two disagreements were noted, which were resolved by discussion and consensus. Two data charting forms were developed iteratively by the authors and used for this review. An initial data charting form, based on examination of published scoping reviews and the research team’s expertise, was created and used. We then added additional data items—author affiliation/disciplinary perspective and “how WSCC was integrated/used” because of the variability we noticed on the initial review. Critical appraisal of individual sources of evidence was conducted using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018) to document the quality of the research articles in our sample.
Initial results searching with “Whole School, Whole Community, Whole Child” or “Whole School Whole Community Whole Child” in peer-reviewed journals yielded 246 articles. All 246 articles were manually reviewed and those that contained the WSCC model name in the title, abstract, or keywords were selected, leaving 38 articles. All 38 articles were reviewed in its entirety for eligibility. Thirty were excluded because they were editorials or book reviews or a commentary on a specific article or not research, leaving eight articles for analysis (Figure 2).
Research studies reviewed are displayed in Online Table 1. Disciplinary perspectives reflected in the articles were primarily in public health (n = 6), followed by education (n = 3), nutrition/dietetics (n = 2), and one each from physical education, justice administration, and interdisciplinary health. Two studies were first authored by researchers from government agencies, while six were published by individuals in academic institutions. Six of the eight studies were published in the JournalofSchoolHealth.
We used the MMAT (Hong et al., 2018) to assess the research studies identified. The MMAT is used to describe the quality of empirical studies. For each type of study design, there are approximately five questions regarding, for example, the sample, setting, analytic methods, and appropriateness of findings. It requires at least two reviewers to independently review each study. Although MMAT is termed an appraisal tool, calculated overall scores from the criterion ratings are discouraged. Rather, the MMAT manual recommends describing each criterion so that the reader is able to make their own individual assessment of the research (Hong et al., 2018). For the eight research articles identified, most study designs were quantitative descriptive (n = 5), with the remaining being qualitative (n = 1) and mixed methods (n = 2). Of the mixed-methods studies, one was an intervention study, while the other was a Delphi study. Four (three quantitative, one qualitative) were secondary analyses of existing data, and three of these were analyses of publicly available national databases.
Samples and settings varied across the research studies. Two studies involved teachers only, while the sample in two others comprised a combination of teachers and staff/administrators. Three studies involved schools or school districts and one (the Delphi study) utilized experts in education, culinary, nutrition, agriculture, and health/public health. Two studies were conducted with students and one included parents, teachers, and community members together.
In terms of analytic methods used, four studies used descriptive statistics; two of these were weighted national samples of teachers and students. Two other studies utilized inferential statistics (analysis of variance and χ2 automatic interaction detection), while two involved qualitative thematic analyses.
The focus of the eight research studies varied considerably and included changes in knowledge, skills, and attitudes; school structure and processes; program implementation; and student health (see Online Table 1). The studies examined teacher satisfaction; support for and attitudes toward health teaching; the existence of school health policies, barriers, and facilitators to implementing physical activity in schools; identification of food education standards; and predictors of student bullying. Findings of these eight studies indicate that overall, implementation of school health policies or programs requires collaboration, compromise, and integration into multiple areas of the school day. Of the studies that examined health policies in schools, those with legislative mandates had more comprehensive school health policies. In one of the three studies examining the implementation of seven components of WSCC among schools nationwide that had policies in those seven areas, authors reported wide variation in the types of implementation practices and less than 27% of schools had school health councils, which are recommended for leading coordination of WSCC implementation (Lee et al., 2019).
Among the eight research studies, the WSCC model was used in a variety of ways, ranging from a simple reference to the model to a study examining change in perception and knowledge about the WSCC framework among students in a health education course (Vamos et al., 2020). Specifically, three studies focused on implementation, including describing the quality and quantity of policies in each domain of the WSCC (DeFosset et al., 2020), describing practices that support schools in implementing WSCC (S. M. Lee et al., 2019), and identifying the importance of collaboration between teachers, parents, and community members to effectively implement the WSCC model (Gamble et al., 2017). One study conducted a pre- and posttest of students enrolled in a teacher education program to assess knowledge of WSCC (Vamos et al., 2020). Three studies did not utilize WSCC in the research but rather used it as a way to report or interpret their findings or to provide future recommendations. For example, Sutter et al. (2019) report findings from a Delphi study to identify food standards in schools and described how their findings aligned with various components of WSCC. Last, one study made a cursory mention of WSCC in the Introduction and did not utilize WSCC in any substantive way (Crowell et al., 2018).
The goal of this scoping review was to document and describe peer-reviewed published research that utilized the WSCC model. Overall, findings from this review reveal a relatively small body (n = 8) of peer-reviewed research. This is somewhat surprising, given that WSCC is presented as a model for schools throughout the United States. Best practice necessitates evidence that supports the model’s theoretical structure and demonstrates that the use of the model results in benefits for the target population. That evidence should be vetted through the peer review process to ensure the quality and rigor of the data. Consequently, as a model for best practice in promoting schools, health, and building a culture of health, the WSCC framework must have a larger presence in the peer-reviewed academic literature to support continued scholarly inquiry; promote intentional, explicit, and robust use of WSCC in research; and further buttress consistency across schools in adopting evidence-based holistic approaches to improving academic and health outcomes.
Since its launch in 2014, only eight research studies have been published, four of which are secondary analyses. Only three studies utilized WSCC explicitly as part of the research by using the specific domains of the WSCC in the methods. The remainder identified the model as guiding the research or interpretation of findings. The limited empirical data on WSCC overall preclude the ability to draw conclusions about the utility and effectiveness of the model in impacting outcomes.
There is wide variation in the focus of the extant research literature, which is expected given the relatively few studies that exist, but this limits any comprehensive synthesis of research findings. Study results include teacher satisfaction and perceptions toward teaching health; challenges/barriers to integrating specific curricula; predictors of behaviors, policies, and standards; and use of WSCC. In particular, our review illuminates the limited empirically based work on the model itself. Rasberry et al. (2015) identified three areas of needed research related to WSCC: integration of the ecological approach that involves the community, identification of concrete strategies for WSCC implementation, and outcomes research to determine the model’s impact as a whole. To date, few research studies have truly adopted an ecological approach in their designs or included the community. Descriptions of community partnerships must be augmented with data on, about, and collected in partnership with community agencies. Implementation research specific to the WSCC model as a whole is also sparse. Last, findings on the impact of using the WSCC model (as opposed to select components) on creating and sustaining healthy school communities are almost absent in the literature, including no comparisons of the relative impact or importance of the 10 different WSCC domains on health. Over time, researchers have documented the link between individual components of the WSCC model and academic success (Anderson, 1982; Maughan, 2003; Murray et al., 2007; Pucher et al., 2013; Sibley & Etnier, 2003), but as noted by Rasberry et al. (2015), understanding the cumulative impact of WSCC on the culture of health in schools is essential to guide schools in developing priorities, policies, and targets for funding applications. Michael et al.’s (2015) literature review provides the evidence that links specific WSCC components to health individually, but a thorough and comprehensive evaluation of this multifaceted model is needed and must be disseminated in peer-reviewed venues that also reach academic researchers.
The difficulty caused by limited extant research on WSCC is magnified by the fact that few disciplinary perspectives are reflected in the publications, despite being an ecological and multidisciplinary framework. The predecessors of WSCC—CSH and WC—were grounded in public health and education, respectively (Lewallen et al., 2015), so it is not unexpected that the early work on WSCC comes from those two fields. However, WSCC is a comprehensive model that recognizes the multiple levels of influences and interactions between individuals and systems on academic success, and thus, perspectives from a variety of disciplines and sectors are needed in examination of the model. In particular, school nurses are the bridge between health and education and are the key health professionals embedded in the school system. Nurses, among others, should be actively represented in work related to WSCC. While we noted three published articles in the overall peerreviewed literature, the nursing perspective is otherwise absent in the research.
The Framework for 20th Century for Professional School Nursing Practice (National Association of School Nurses, 2016) articulates the multiple roles of the school nurse in supporting students and schools, and these align with the WSCC model. School nurses, as leaders, coordinators, and advocates, are well positioned to lead and disseminate information about their efforts to ensure that schools are adopting the WSCC model/approach. Other disciplines that could provide input in terms of implementation and evaluation include school psychology, school counseling, psychology, psychiatry, primary care, and social work. Similarly, findings from this review demonstrate that literature on and about WSCC is predominately located in one journal—the Journal of School Health. In addition to needing to encourage interprofessional perspectives in published literature, research and dissemination efforts must extend to various disciplinary journals to expand the reach of WSCC.
There are limitations to this review which require acknowledgment. We wanted to focus on published literature addressing the WSCC model specifically and, as such, searched only on those terms. Our decision to search for this model by name eliminated results that focus on other student health programs or discuss student health programs generally. However, this could mean that we missed articles that discuss WSCC in their full text, but we approached the search with the assumption that any research that focused on this model would include WSCC in one of those searchable fields. Similarly, in our manual review of the initial 246 articles, our assumption that if a publication was focused on the WSCC model, it would be referenced in the title, abstract, or article key words might have been inaccurate. Last, although WSCC is designed for use in schools to promote health, it could be that other nonhealth, education, or psychology databases not included in our search may contain publications about WSCC, thereby omitting other peerreviewed publications. Despite these limitations, our search methodology followed conventional literature search approaches, and our findings provide a glimpse into the current research on the WSCC model that can serve as a guide for future research.
Findings suggest several areas where school nurses may be impactful. The limited presence of publications about the WSCC model by, or including, school nurses highlights opportunities for school nurses in practice, research, and education. School nurses lead, coordinate, and advocate for students to advance students’ well-being and academic success by working across and within multiple systems and across disciplines. In these roles, school nurses are ideally situated to collaborate with school professionals and the community to support the coordination efforts required to comprehensively implement WSCC in schools. Efforts to understand the cumulative impact of adopting the WSCC model in schools should, ideally, be undertaken by school nurses. School nursing practice integrates multiple disciplinary perspectives and knowledge.
Research on the WSCC model is clearly needed. The expertise of school nurses in evidence-based practice provides a strong foundation to engage in or assist researchers in understanding how to conduct relevant practice-based research in a school setting and thereby contribute to the much-needed empirical data on the WSCC model. School nursing educators may also more intentionally integrate the WSCC model in curricula to ensure that future school nurses are grounded in its approach. These strategies together will not only support and contribute to the visibility of school nurses’ involvement in WSCC implementation but also facilitate research that demonstrates the interrelatedness between the WSCC model and school nursing practice.
Empirical evidence on the utility of the WSCC model in supporting a culture of health remains limited, despite widespread use of the model in practice. Further, the current literature related to WSCC is confined to relatively few disciplines; leveraging opportunities to encourage other disciplines to incorporate WSCC into their work would strengthen its use across the 10-model components. This review points to the need for concerted efforts to engage in implementation and evaluation research of the whole WSCC. School nurses have the opportunity to lead these efforts.
Mayumi A. Willgerodt, Elaine Walsh, and Caitlin Maloy contributed to conception, design, acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Mayumi A. Willgerodt, PhD, MPH, RN, FAAN, FNASN https://orcid.org/0000-0002-9874-3739
Supplemental material for this article is available online.
Anderson, C. S. (1982). The search for school climate: A review of the research. Review of Educational Research, 52(3), 368–420. https://doi.org/10.3102/00346543052003368
Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodolgy, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616
Association for Supervision and Curriculum Development & Centers for Disease Control and Prevention. (2014). Whole School, Whole Community, Whole Child: A collaborative approach to learning and health. Retrieved May 10, 2020, from http://www.ascd.org/programs/learning-and-health/wscc-model.aspx
Chiang, R. J., Meagher, W., & Slade, S. (2015). How the Whole School, Whole Community, Whole Child model works: Creating greater alignment, integration, and collaboration between health and education. Journal of School Health, 85(11), 775–784. https://doi.org/10.1111/josh.12308
Collaboratory on School and Child Health. (n.d.). WSCC: Think about the Link Project.
Hong, Q. N., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., Gagnon, M. P., Griffiths, F., Nicolau, B., O’Cathain, A., Rousseau, M. C., Vedel, I., & Pluye, P. (2018). The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Education for Information, 34(4), 285–291. https://doi.org/10.3233/EFI-180221
Lee, C. J., & Moher, D. (2017). Promote scientific integrity via journal peer review data. Science, 357(6348), 256–257.
Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science, 5(69), 1–9. https://doi.org/10.1186/1748-5908-5-69
Lewallen, T. C., Hunt, H., Potts-Datema, W., Zaza, S., & Giles, W. (2015). The Whole School, Whole Community, Whole Child model: A new approach for improving educational attainment and healthy development for students. Journal of School Health, 85(11), 729–739. https://doi.org/10.1111/josh.12310
Maughan, E. (2003). The impact of school nursing on school performance: A research synthesis. The Journal of School Nursing, 19(3), 163–171. https://doi.org/10.1177/10598405030190030701
Michael,S.L.,Merlo,C.L.,Basch,C.E.,Wentzel,K.R.,& Wechsler, H. (2015). Critical connections: Health and academics. JournalofSchoolHealth, 85(11), 740–758. https://doi.org/10.1111/josh.12309
Moher, D., Liberati, A., & Tetzlaff, J. A. D. (2009). PRISMA 2009 flow diagram: In the PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed1000097
Moyer, M. T., Foley, J. T., Hodges, B. C., &Pace, J. (2016). A practical approach to enhancing a healthy school community by adopting the WSCC model. Health Educator, 48(2), 2–6. http://offcampus.lib.washington.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=125354545&site=ehost-live
Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Medical Research Methodology, 18(142), 1–7. https://doi.org/10.1186/s12874-018-0611-x
Murray, N. G., Low, B. J., Hollis, C., Cross, A. W., & Davis, S. M. (2007). Coordinated school health programs and academic achievement: A systematic review of the literature. Journal of School Health, 77(9), 589–600. https://doi.org/10.1111/j.1746-1561.2007.00238.x
National Association of Chronic Disease Directors. (2017). The Whole School, Whole Community, Whole Child model: A guide to implementation. National Association of Chronic Disease Directors.
National Association of School Nurses. (2016). Framework for 21st century school nursing practice: National Association of School Nurses. NASN School Nurse, 31(1), 45–53. https://doi.org/10.1177/1942602X15618644
National Association of School Nurses. (2017). Whole School, Whole Community, Whole Child: Implications for 21st century school nurses [Position statement]. https://www.nasn.org/advocacy/professional-practice-documents/position-statements/pswscc
Pucher, K. K., Boot, N., & de Vries, N. K. (2013). Systematic review: School health promotion interventions targeting physical activity and nutrition can improve academic performance in primary and middle school children. Health Education, 113(5), 372–391. https://doi.org/10.1108/HE-02-2012-0013
Rasberry, C. N., Slade, S., Lohrmann, D. K., & Valois, R. F. (2015). Lessons learned from the whole child and coordinated school health approaches. Journal of School Health, 85(11), 759–765. https://doi.org/10.1111/josh.12307
Sibley, B. A., & Etnier, J. L. (2003). The relationship between physical activity and cognition in children: A meta-analysis. Pediatric Exercise Science, 15(3), 243–256. https://doi.org/10.1123/pes.15.3.243
Siegel, V. (2008). The promise of peer review. Disease, Models, & Mechanisms, 1(2–3), 73–77.
Mayumi A. Willgerodt, PhD, MPH, RN, FAAN, FNASN, is Associate Professor and Vice-Chair, Education in the Department of Child, Family, and Population Health Nursing, University of Washington, Seattle.
Elaine Walsh, PhD, RN, PMHCNS-BC, FAAN, is Associate Professor in the Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, and Research Scientist at Seattle Children’s Hospital, Seattle, Washington.
Caitlin Maloy, MLIS, is Research and Data Services Librarian at University of Washington, Seattle.
1 University of Washington, Seattle, WA, USA
Corresponding Author:Mayumi A. Willgerodt, PhD, MPH, RN, FAAN, FNASN, Department of Child, Family, and Population Health Nursing, University of Washington, Box 357262, Seattle, WA 98195, USA.Email: mayumiw@uw.edu
