Improving Care of Inner-City Children with Poorly Controlled Asthma: What Mothers Want You to Know

A home visit program for low-income African American children with asthma: Caregivers' perception of asthma triggers and a gap in action

PURPOSE

The goals are to gauge caregivers' knowledge of at-home asthma triggers and identify the areas on which educational campaigns can focus to alleviate a child's asthma symptoms.

DESIGN AND METHODS

Families with children with moderate to severe asthmatic symptoms who had been recently hospitalized or in the emergency room were invited to participate in a home visit program. As part of the home visit, caregivers of the asthmatic children were asked a series of questions on asthma triggers and the measures for eliminating the triggers (N = 218).

RESULTS

Findings show a gap between caregivers' perception of asthma triggers and the actions to mitigate or avoid such triggers.

CONCLUSIONS

Overall findings show that home environments were suboptimal for the management and control of child asthma conditions. Knowledge about home triggers as well as the actions and efforts by caregivers and landlords to mitigate these was found to be inadequate. Even when caregivers are aware of the presence of at-home triggers, actions to minimize exposure to the trigger do not always follow due to a lack of power, resource, and knowledge.

PRACTICE IMPLICATIONS

The findings raise the need for additional research to investigate the reasons for the lack of actions, advocacy for low-income families to live in a healthy environment, continued education and empowerment, and patient/caregiver-doctor partnership. Additionally, the provision of community support through community advocacy and training of culturally competent healthcare providers are needed for the successful management of pediatric asthma among African American children.

Caregiver Depressive Symptoms and Primary Medication Nonadherence in Children With Asthma

INTRODUCTION

The purpose of this study was to identify risk factors for primary medication nonadherence among low-income minority children with persistent asthma.

METHOD

Data were from an environmental control and educational intervention for children with uncontrolled asthma who were treated in the emergency department for an asthma exacerbation. Presence or absence of pharmacy records for child asthma medications was the outcome of interest. A range of sociodemographic, health, and psychosocial measures were included in the binary logistic regression.

RESULTS

Of the 222 youths (mean age = 6.3 years; 93.7% Black), 25 (11.3%) lacked pharmacy records of asthma medications. For every 1-point increase in caregiver depressive symptoms, the odds of the child having a pharmacy record declined by 5% (odds ratio = 0.95; p = .012).

DISCUSSION

Providers should systematically assess and monitor caregiver depressive symptoms as a potential contributing factor for primary medication nonadherence in low-income minority children with persistent, uncontrolled asthma.

Parents' self-reported experiences and information needs related to acute pediatric asthma exacerbations: A mixed studies systematic review

Objective

To systematically review the scientific literature examining parents' experiences and information needs for the management of their child's asthma exacerbations.

Methods

We searched five databases for quantitative and qualitative studies in Canada and the United States from 2002 onwards. A convergent integrated approach and the Mixed Method Appraisal Tool were used to analyze and appraise the evidence, respectively.

Results

We included 84 studies (27 quantitative, 54 qualitative, 3 mixed methods). Some parents lacked confidence in recognizing or managing exacerbations. A few parents were uncertain when and where to seek medical help. The main barrier to accessing care was cost. Impacts on parents included poor sleep, distress, and lifestyle disruptions. Parents felt they lacked information and wanted education on treatments and how to recognize and manage exacerbations via education sessions, written materials, community outreach and online resources.

Conclusion

Improved education for parents may help reduce parents' stress, asthma-related morbidities for children and use of urgent health services.

Innovation

The development of tailored interventions and knowledge translation strategies with input from target audiences (e.g. parents, health care providers) is necessary to meet their information needs and support adherence to clinical recommendations.

•

84 studies reviewed and analyzed using the convergent integrated approach

•

Parents lacked confidence in recognizing, treating or seeking care for exacerbations

•

Cost was a barrier to care; parents affected by psychosocial impacts

•

Parent's desired education on treatments and how to recognize and manage exacerbations

•

Interventions and knowledge translation strategies must be developed with parents

A Computer-Based Interactive Narrative and a Serious Game for Children With Asthma: Development and Content Validity Analysis

Background

Nonadherence to medications, failure to prevent exposure to asthma triggers, lack of knowledge about using medications, and fixed mindsets contribute to poor asthma control in children. Digital learning could provide a new strategy for improving health-related outcomes in children with asthma.

Objective

The aim of this study is to develop and design a digital educational program, titled Module of Inhaler and Asthma Triggers for Children (MIRACLE), for Indonesian children with asthma. The program comprises an interactive narrative and a serious game. It was proposed to increase the understanding of asthma self-management, instruct on proper inhaler techniques, improve asthma control, and promote a growth mindset for children with asthma.

Methods

Two phases of research were conducted to develop the program. In the first phase, a literature search and two rounds of the Delphi technique were conducted to obtain agreement from an expert panel regarding elements of asthma self-management and the design of interactive narratives and a serious game. The expert panel item statements were evaluated using the content validity index (CVI). In the second phase, the SERES framework, Norma Engaging Multimedia Design, and Psychological Theory of Growth Mindset were applied to create a storyline, learn objectives, and game challenges.

Results

In the first phase, 40 experts were invited to participate in Delphi round 1. Forty responses were collected to generate 38 item statements that consisted of part 1, elements of asthma self-management (25 items), and part 2, design of an interactive narrative and a serious game (13 items); 38 experts were involved in Delphi round 2. In total, 24 statements in part 1 and 13 items in part 2 had item-CVI values >0.80. The average CVI was 0.9, which was considered acceptable. Four narrative plots and five game sessions were developed during the second phase. Challenges with the scenario, scoring, and feedback on asthma difficulties were designed to promote a growth mindset for learners.

Conclusions

We developed a culture-specific, computer-based asthma program containing an interactive narrative and a serious game to deliver asthma self-management and promote a growth mindset among Indonesian children.

The Effects of Caregiver Social Support and Depressive Symptoms on Child Medication Adherence and Asthma Control

The purpose of this study was to examine relationships among caregiver social support, caregiver depressive symptoms, medication adherence, and asthma control in a sample of low-income, urban, Black children aged 3–12 years with uncontrolled asthma and their caregivers. Using longitudinal data from a randomized controlled trial (RCT) assessing the efficacy of an environmental control educational intervention, we used generalized estimating equations and ordered logistic regression models to evaluate the relationship between caregiver social support (Medical Outcomes Study Social Support Survey), depressive symptoms (Center for Epidemiologic Studies Depression scale), and two child asthma outcomes: (a) medication adherence (Asthma Medication Ratio) and (b) asthma control. At baseline, 45.7% of the 208 children had very poorly controlled asthma. Nearly a third of caregivers (97% female) had clinically significant depressive symptoms at each data collection point. Social support was not associated with either asthma outcome nor did it moderate the relationship between depressive symptoms and child asthma outcomes. Higher caregiver depressive symptoms predicted decreased medication adherence (b=−0.003, SE 0.002). Moderate asthma at baseline (OR: 0.305, SE: 0.251), severe asthma at baseline (OR: 0.142, SE: 0.299), household income < $20,000 per year (OR: 0.505, SE: 0.333), and fall season (OR: 0.643, SE: 0.215) were associated with poorer asthma control. Attending to the social context of low-income, urban, Black children with asthma is critical to reduce asthma morbidity. Maternal depressive symptoms are modifiable and should be targeted in interventions to improve child asthma outcomes in this vulnerable population. The RCT was registered with ClinicalTrials.gov (NCT01981564) in October 2013.

Barriers and Facilitators of Asthma Management as Experienced by African American Caregivers of Children with Asthma: An Integrative Review

INTRODUCTION

African American children with asthma demonstrate significant health disparities and poor health outcomes. Understanding the burdens faced by parents and caregivers of children with asthma may be helpful to develop future interventions to address this disparity.

PURPOSE

The purpose of this integrative review was to reveal the barriers and facilitators of child asthma management experienced by African American caregivers.

METHOD

Whittemore and Knafl's (2005) method of integrative review was used to review 40 articles. The integrative review involved appraising the quality of the literature, conducting a thematic analysis, and evaluating the barriers and facilitators of pediatric asthma management experienced by African American caregivers.

RESULTS

Barriers and facilitators were identified as themes. Barriers included caregiver burdens, and lack of home and neighborhood safety. Facilitators were family and community support, education and empowerment, and culturally competent healthcare providers.

DISCUSSION

To improve the care of African American children with asthma, nurses should work to engage, communicate, and foster trust with families. Nurses should assess and address the family caregivers' burdens while emphasizing support systems.

The Impact of Social Determinants of Health on Children with Asthma

SzAsthma is the most common chronic disease of childhood. Disparities in asthma outcomes have led to international attention on the biologic, social, economic, and other factors that impact the health of children with asthma. Studies indicate that social determinants of health such as housing, neighborhood safety, and access to care significantly impact the health of children with asthma. However, screening for socioeconomic and environmental factors that impact asthma can be difficult to integrate into clinical practice. In addition, it is not yet clear which interventions to address these factors are most effective. This article will review recent studies of determinants and social determinants of health and propose a framework for identifying and addressing them in the care of children with asthma in a clinical setting.

Fostering Effective Asthma Self-Management Transfer in High-Risk Children: Gaps and Opportunities for Family Engagement

INTRODUCTION

The process of self-management knowledge, behavior, and skill development in children with asthma from families with low income is understudied.

METHOD

Fifteen mothers of children with uncontrolled asthma participated in semistructured interviews exploring the transfer of asthma self-management responsibilities from parent to child. Team members performed thematic analysis of written transcripts.

RESULTS

All participants were all the biological mothers and were impoverished, with most (73%) reporting an annual family income of less than $30,000. Their children ranged from 5 to 15 years old, were African American (100%), and had uncontrolled asthma based on national guidelines. Themes showed that child asthma self-management is difficult to achieve, that the transfer of asthma responsibility from mother to child is variable, and that mothers overestimate their child's developmental capacities for independent asthma self-management and have poor understanding of what well-controlled asthma means.

DISCUSSION

Ongoing assessment and tailored guidance from health care providers are critical to support the pivotal role of mothers in their child's self-management development process.

Tailored medication adherence incentives for high-risk children with asthma: a pilot study

Objective: While reminder-based electronic monitoring systems have shown promise in enhancing inhaled corticosteroid (ICS) adherence in select populations, more engaging strategies may be needed in families of children with high-risk asthma. This study assesses the acceptability and feasibility of gain-framed ICS adherence incentives in families of urban, minority children with frequent asthma hospitalization.Methods: We enrolled children aged 5-11 years with multiple yearly asthma hospitalizations in a 2-month, mixed methods, ICS adherence incentive pilot study. All participants received inhaler sensors and a smartphone app to track ICS use. During month 1, families received daily adherence reminders and weekly feedback, and children earned up to $1/day for complete adherence. No reminders, feedback, or incentives were provided in month 2. We assessed feasibility and acceptability using caregiver surveys and semi-structured interviews and ICS adherence using electronic monitoring data.Results: Of the 29 families approached, 20 enrolled (69%). Participants were primarily Black (95%), publicly insured (75%), and averaged 2.9 asthma hospitalizations in the prior year. Fifteen of the 16 caregivers (94%) surveyed at month 2 liked the idea of receiving adherence incentives. Mean adherence was significantly higher in month 1 compared with month 2 (80% vs. 33%, mean difference = 47%; 95% CI [33, 61], p < 0.001). Caregivers reported that their competing priorities often limited adherence, while incentives helped motivate child adherence.Conclusions: ICS adherence incentives were acceptable and feasible in a high-risk cohort of children with asthma. Future studies should assess the efficacy of adherence incentives in enhancing ICS adherence in high-risk children.

What Means A Quality Professional-Patient Relationship From The Asthmatic Patients' Perspective? A Narrative Review Of Their Needs And Expectations

INTRODUCTION

Poor treatment adherence among asthmatic patients currently remains a public health challenge. One of the most quoted determinants is the quality of the professional-patient relationship although it has clearly not been fully described.

PURPOSE

This study aims at deeply exploring asthmatic patients' needs and expectations about the accompaniment proposed by their healthcare professionals.

METHODS

A rigorous narrative review was performed.

RESULTS

According to patients, what they expect from professionals can be split into eight themes: getting exhaustive information, relying on an available healthcare professional, being more involved into life with one's asthma, being accompanied by a multidisciplinary team, being respected in one's uniqueness, being cared through a humanist approach, feeling the professional is skilled and Other needs.

DISCUSSION AND CONCLUSION

Asthmatic patients' needs have little evolved in 20 years illustrating that if they are met, that would positively affect the way patients want to be followed by healthcare professionals and so, that would increase their treatment adherence. Several recommendations such as setting up a doctor - asthma nurse practitioner binomial or studying a concrete care pathway may help in fulfilling these needs. Finally, this research opens the way to other studies since similar results have been found in populations suffering from other chronic diseases than asthma.