Asthma management practices at home in young inner-city children

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

CARE: an observational study of adherence to home nebulizer therapy among children with asthma

Background:

The prevalence of pediatric asthma in China is approximately 3%, and asthma remains poorly controlled in many of these patients. This study assessed the rate of adherence to home nebulizer treatment in paediatric patients in China.

Methods:

The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0–14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers).

Results:

The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control.

Conclusions:

Adherence to home nebulization, a widely used treatment for asthma, was high among Chinese pediatric patients. Asthma control improved with increasing treatment duration. These results suggest that home nebulization of ICS is an effective and recommendable long-term treatment for paediatric patients with asthma.

Trial registration

ClinicalTrials.gov identifier: NCT03156998

The reviews of this paper are available via the supplemental material section.

A Low-Literacy Asthma Action Plan to Improve Provider Asthma Counseling: A Randomized Study

BACKGROUND AND OBJECTIVES

The use of written asthma action plans (WAAPs) has been associated with reduced asthma-related morbidity, but there are concerns about their complexity. We developed a health literacy-informed, pictogram- and photograph-based WAAP and examined whether providers who used it, with no training, would have better asthma counseling quality compared with those who used a standard plan.

METHODS

Physicians at 2 academic centers randomized to use a low-literacy or standard action plan (American Academy of Allergy, Asthma and Immunology) to counsel the hypothetical parent of child with moderate persistent asthma (regimen: Flovent 110 μg 2 puffs twice daily, Singulair 5 mg daily, Albuterol 2 puffs every 4 hours as needed). Two blinded raters independently reviewed counseling transcriptions.

PRIMARY OUTCOME MEASURES

medication instructions presented with times of day (eg, morning and night vs number of times per day) and inhaler color; spacer use recommended; need for everyday medications, even when sick, addressed; and explicit symptoms used.

RESULTS

119 providers were randomly assigned (61 low literacy, 58 standard). Providers who used the low-literacy plan were more likely to use times of day (eg, Flovent morning and night, 96.7% vs 51.7%, P < .001; odds ratio [OR] = 27.5; 95% confidence interval [CI], 6.1-123.4), recommend spacer use (eg, Albuterol, 83.6% vs 43.1%, P < .001; OR = 6.7; 95% CI, 2.9-15.8), address need for daily medications when sick (93.4% vs 34.5%, P < .001; OR = 27.1; 95% CI, 8.6-85.4), use explicit symptoms (eg, "ribs show when breathing," 54.1% vs 3.4%, P < .001; OR = 33.0; 95% CI, 7.4-147.5). Few mentioned inhaler color. Mean (SD) counseling time was similar (3.9 [2.5] vs 3.8 [2.6] minutes, P = .8).

CONCLUSIONS

Use of a low-literacy WAAP improves the quality of asthma counseling by helping providers target key issues by using recommended clear communication principles.

The relationships among family management behaviors and asthma morbidity in maternal caregivers of children with asthma

Numerous studies have identified the relationship of the family caregiver's perception regarding asthma management and the child's asthma outcomes, although few have examined family caregiver asthma management behaviors. The primary aim of this study was to examine the relationship among family management behaviors and asthma morbidity as perceived by maternal caregivers. The Family Management Style Framework was used to guide the research. Maternal caregivers (N = 101) with school-aged children diagnosed with persistent asthma and living in the United States were recruited from a specialty asthma clinic. When caregivers perceived they were expending much effort on their child's asthma management and were not confident in their ability to perform management activities, the child's asthma outcomes were worse. This is the first study to examine family management behaviors with maternal caregivers of school-aged children with asthma. Findings from this study encourage health care providers to tailor each educational opportunity with families to improve child asthma outcomes. An ongoing effort must be made to include families in asthma management. Health care partnerships between provider and family can lead to improved asthma management.

Review of the management of childhood asthma in Tasmania

AIM

To review the supply of medications to children with asthma and parent-reported management of childhood asthma in Tasmania and highlight evidence-practice gaps for future interventions.

METHODS

Participating pharmacies ran a software application that extracted data from dispensing records and helped to identify children with asthma. Parents of identified children were mailed a survey evaluating components of asthma management. Dispensing and survey data were analysed.

RESULTS

A total of 939 children from 23 pharmacies were identified by the software and deemed eligible for inclusion. Surveys were received from 353 (37.6%) parents. In the past year, short-acting beta-2 agonists were supplied to 56.1% of the cohort, preventers to 76.5% (inhaled corticosteroids 52.3%; leukotriene receptor antagonists 31.3%; inhaled cromones 0.6%), long-acting beta-2 agonists (LABAs) to 25.7% and oral corticosteroids to 21.5%. Approximately half of the children receiving inhaled corticosteroids were concurrently receiving a LABA. Among children with indicators of inadequately controlled asthma, up to 73.7% of their parents reported that their asthma was adequately controlled, up to 38.2% did not possess an Asthma Action Plan, up to 36.8% were not regularly using a spacer and up to 22.8% had not received a preventer.

CONCLUSION

These results indicate gaps in childhood asthma management, in particular, undersupply of preventers in high-risk patient groups, high supply of LABAs and insufficient spacer and asthma action plan usage. These areas should be targeted for interventions to improve childhood asthma management.

Parent-child agreement in report of nighttime respiratory symptoms and sleep disruptions and quality

INTRODUCTION

Asthma control requires assessment of nighttime symptoms and sleep disruption. Cognitive and emotional development enables most school-aged children to report nocturnal problems, but providers often rely only on parental report, potentially limiting the comprehensiveness of their assessments and their ability to support the child's emerging efforts at shared management of their illness. This study investigated parent-child concordance in report of nighttime respiratory symptoms, sleep disruption, and quality of sleep in a sample of 9- to 11-year-old children with asthma. Secondarily, similar concordance patterns in an equal number of dyads where the child was asthma free were examined to illustrate the potential influence of asthma.

METHOD

Parents and children completed 1-week diaries in their homes without confiding in one another. The probability of knowing the child's report on a specific item if the parent's report was known was assessed using contingency tables.

RESULTS

Within the asthma group, parent-child reports differed significantly across all symptoms and sleep parameters. Parents most often reported fewer symptoms and awakenings and better quality of sleep than did their child. Concordance rates were lowest for morning perceptions of tiredness, sleepiness, and alertness in both asthma and non-asthma groups.

DISCUSSION

Both parents and school-aged children with asthma need to be asked about nighttime asthma symptoms, sleep, and morning perceptions when attempting to evaluate asthma control. Assessment of sleep in all children should include parent and child reports and would benefit by the addition of objective measures.

Home use of albuterol for asthma exacerbations

BACKGROUND

To reduce symptoms and emergency department (ED) visits, the National Asthma Education and Prevention Program (NAEPP) guidelines recommend early treatment of acute asthma symptoms with albuterol and oral corticosteroids. Yet, ED visits for asthma are frequent and often occur several days after onset of increased symptoms, particularly for children from low-income, urban neighborhoods.

OBJECTIVES

To describe home use of albuterol and identify factors associated with appropriate albuterol use.

METHODS

A total of 114 caregivers in the intervention group of a randomized trial to reduce emergent care for low-income, urban children completed a structured telephone interview with an asthma nurse to evaluate home management of their child's acute asthma symptoms. Interviews lasted approximately 20 minutes and were conducted from November 5, 2003, through September 30, 2005. Albuterol use as reported by caregivers was categorized as appropriate or inappropriate based on NAEPP recommendations.

RESULTS

Albuterol use for worsening asthma symptoms was categorized as appropriate for only 68% of caregivers and was more likely if the children had an ED visit or hospitalization for asthma in the prior year. The remaining 32% of caregivers used albuterol inappropriately (overtreatment or undertreatment). Appropriate albuterol use was not associated with caregiver report of having an asthma action plan (AAP) or a recent primary care physician visit to discuss asthma maintenance care.

CONCLUSIONS

Caregivers reported that they would use albuterol to treat their child's worsening asthma symptoms, but many described inappropriate use. Detailed evaluation of proper albuterol use at home may provide insight into how health care professionals can better educate and support parents in their management of acute exacerbations and more effective use of AAPs.

Urban minority children with asthma: substantial morbidity, compromised quality and access to specialists, and the importance of poverty and specialty care

BACKGROUND

Asthma disproportionately affects minorities, but not enough is known about morbidity and specialist access in asthmatic minority children.

OBJECTIVE

To examine asthma morbidity and access to specialty care in urban minority children.

METHODS

A consecutive series was recruited in 2004-2007 of urban minority children 2 to 18 years old seen for asthma in four emergency departments (EDs) or admitted to a children's hospital. Outcomes assessed included asthma symptom and attack frequency; missed school and parental work; asthma ED visits and hospitalizations; severity of illness; and asthma specialty care.

RESULTS

Of 648 children assessed, 220 were eligible. The mean age was 7 years; 68% were poor, 83% had Medicaid, 84% were African-American, and 16% were Latino. Sixty-eight percent of children were not in excellent/very good health, 73% had persistent asthma (moderate/severe = 52%), and only 44% had asthma care plans. The mean number of asthma attacks in the past year was 12, and of monthly daytime and nighttime asthma symptoms, is 12 and 12, respectively. The mean annual number of asthma doctor visits was 6; of ED asthma visits, 3; hospitalizations, 1; missed school days, 7; and missed parent work days, 6. Eighty-three percent of children have no asthma specialist, and 62% use EDs as the usual asthma care source. Poor children were less likely than the non-poor to have asthma specialists (13 vs. 26%; p < 0.03). African-Americans were more likely than Latinos to use EDs for usual asthma care (68% vs. 44%; p < 0.01). In multivariable analyses, poverty was associated with greater odds and having an asthma care plan with lower odds of an asthma attack in the past year; poverty also was associated with half the odds of having an asthma specialist. African-American children were significantly more likely to report the ED as the usual source of asthma care, and having an asthma specialist and male gender were associated with greater odds of having an asthma care plan.

CONCLUSIONS

Urban minority children with asthma average 1 asthma symptom daily, 1 exacerbation monthly, and 7 missed school days, 6 missed parental work days, 3 ED visits, and 1 hospitalization yearly; most receive their usual asthma care in EDs and have no asthma care plan or asthma specialist. Urban minority asthmatic children need interventions to reduce morbidity and improve access to specialists and asthma care plans, especially among the poor and African-Americans.

Acute asthma management by a pediatric after-hours call center

To describe an asthma management protocol used in a nurse-staffed pediatric After-Hours Call Center (AHCC) that incorporates severity-based home treatment recommendations and follow-up call assessments. Call records for asthma advice from January 1, 2004 to June 30, 2004 were identified retrospectively and reviewed. Descriptive statistics were used to report patient demographics, frequencies of symptom severity zones (Red, Yellow, or Green) at initial calls, frequencies of call dispositions designating care advice provided (including home treatment recommendations and seeking emergency department [ED] care), and changes in severity zones between initial calls and follow-up calls when nurses reassessed patients after recommended home treatment. During the study period, 3,632 asthma calls (2,439 initial; 1,193 follow-up) were managed by AHCC nurses. Initial calls were classified mostly as Red (28%) or Yellow (42%) severity zones; 27% were Green zone and 3% could not be categorized. Fifty-two percent of initial calls with Red or Yellow severity zones involved home treatment recommendations; 50% of those Red zone and 63% of those Yellow zone calls had improved severity zones at follow-up call assessments. Twenty-eight percent of patients with home treatment recommendations were referred to the ED at the time of follow-up call nurse reassessment. This telephone-based nurse-staffed pediatric acute asthma management protocol includes provision of severity-based home treatment recommendations and follow-up assessments, and improved symptoms for many children with acute exacerbations. This protocol may also be successful in other locations and may improve outcomes, such as reduction in ED visits.

Formulating an effective and efficient written asthma action plan

Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician's busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.

The impact of literacy enhancement on asthma-related outcomes among underserved children

STATEMENT OF PROBLEM

Despite the availability of improved healthcare access, self-management programs, disease management protocols, and advances in pharmacologic and immunotherapy therapy, the prevalence of asthma in the urban inner city remains one of the major health disparities in the United States. Additionally, sustainability of effective intervention programs after the funding has ended remains a significant issue for asthma programs.

OBJECTIVE

This study examines the effectiveness of a longitudinal intervention program that was designed with the assumption that improved literacy plays a role in improving asthma-related health outcomes among high-risk children with the most severe forms of asthma.

METHODS

A longitudinal intervention over 6 months prospectively addressed the literacy and asthma self-management skills of 110 minority children in South Los Angeles utilizing weekly Saturday-school format.

RESULTS

The results demonstrated that there was a statistically significant decrease in both hospitalization and emergency department (ED) visits during the intervention. In addition, all the children showed significant improvement in their reading level and self-efficacy. Multivariate logistic analysis demonstrated that enhanced self-efficacy was directly related to decreased hospitalizations and ED visits.

CONCLUSION

This intervention demonstrated that literacy enhancement is an important factor in improving self-efficacy and impacting asthma-related outcomes. Improved literacy is a sustainable factor that will not only improve asthma outcomes but will enhance the potential for educational success.

One gets so afraid: Latino families and asthma management--an exploratory study

INTRODUCTION

This study explored Latino family experiences, issues, and needs in caring for a child with asthma as expressed by Latino parents of children with asthma.

METHODS

Eight families represented by 7 women and 2 men, primarily of Mexican descent, participated in the study. All families had at least one child enrolled in preschools in the East Los Angeles area. The study had an exploratory design and used ethnographic group and individual interview techniques to discover the parents' experiences in managing their child's asthma and the meaning asthma has for their families. All interviews were conducted in Spanish.

RESULTS

Several common themes emerged from the data: (a) fear, "I got scared"; (b) the acute care experience, "I was not told what to do, nothing"; (c) knowledge, "I did not know anything about asthma"; and (d) parent alternative strategies or strengths, "We want to do what is best. ... we need to be prepared."

DISCUSSION

Strength emerged from fear. The parents were resourceful and began developing alternative strategies to assist them in their care for their child with asthma. The findings emphasize the need for more opportunities for culturally sensitive asthma education and community health care resources such as mobile asthma treatment centers and promotora programs.

Pharmacy fill patterns in young urban children with persistent asthma

BACKGROUND

Medication adherence impacts healthcare utilization. Pharmacy records are useful to establish fill patterns.

OBJECTIVE

Use pharmacy records to establish medication patterns fill patterns for comparison to healthcare utilization. Methods. Pharmacy records of 175 children with persistent asthma were collected and compared to healthcare utilization.

RESULTS

Majority of subjects had significant healthcare utilization, low numbers of rescue medications, and poor controller medication fill rates. Those with more rescue medications had more healthcare utilization and more controller medications.

CONCLUSIONS

Pharmacy fill patterns demonstrate few rescue and/or controller medication fills. Those with more rescue medications reported increased healthcare utilization despite controller medications.