Psychosocial Moderators and Outcomes of a Randomized Effectiveness Trial for Child Asthma

Home-based educational interventions for children with asthma

BACKGROUND

Asthma is a chronic airway condition with a global prevalence of 262.4 million people. Asthma education is an essential component of management and includes provision of information on the disease process and self-management skills development such as trigger avoidance. Education may be provided in various settings. The home setting allows educators to reach populations (e.g. financially poor) that may experience barriers to care (e.g. transport limitations) within a familiar environment, and allows for avoidance of attendance at healthcare settings. However, it is unknown if education delivered in the home is superior to usual care or the same education delivered elsewhere. There are large variations in asthma education programmes (e.g. patient-specific content versus broad asthma education, number/frequency/duration of education sessions). This is an update of the 2011 review with 14 new studies added.

OBJECTIVES

To assess the effects of educational interventions for asthma, delivered in the home to children, their caregivers, or both, on asthma-related outcomes.

SEARCH METHODS

We searched Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, two additional databases and two clinical trials registries. We searched reference lists of included trials/review articles (last search October 2022), and contacted authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials of education delivered in the home to children and adolescents (aged two to 18 years) with asthma, their caregivers or both. We included self-management programmes, delivered face-to-face and aimed at changing behaviour (e.g. medication/inhaler technique education). Eligible control groups were usual care, waiting list or less-intensive education (e.g. shorter, fewer sessions) delivered outside or within the home. We excluded studies with mixed-disease populations and without a face-to-face component (e.g. telephone only).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality, extracted data and used GRADE to rate the certainty of the evidence. We contacted study authors for additional information. We pooled continuous data with mean difference (MD) and 95% confidence intervals (CI). We used a random-effects model and performed sensitivity analyses with a fixed-effect model. When combining dichotomous and continuous data, we used generic inverse variance, using a Peto odds ratio (OR) and fixed-effect model. Primary outcomes were exacerbations leading to emergency department visits and exacerbations requiring a course of oral corticosteroids. Six months was the primary time point for outcomes. The summary of findings tables reported on the primary outcomes, and quality of life, daytime symptoms, days missed from school and exacerbations leading to hospitalisations.

MAIN RESULTS

This review includes 26 studies with 5122 participants (14 studies and 2761 participants new to this update). Sixteen studies (3668 participants) were included in meta-analyses. There was substantial clinical diversity. Participants differed in age (range 1 to 18 years old) and asthma severity (mild to severe). The context and content of educational interventions also varied, as did the aims of the studies (e.g. reducing healthcare utilisation, improving quality of life) and there was diversity in control group event rates. Outcomes were measured over various time points specified in the original studies. All studies were at risk of bias due to the nature of the intervention. It is possible that the participants/educators may not have been aware of their allocation, so all studies were judged at unclear risk for performance bias. Home-based education versus usual care, waiting list or less-intensive education programme delivered outside the home Primary outcomes Home-based education may result in little to no difference in exacerbations leading to emergency department visits at six-month follow-up compared to control, but the evidence is very uncertain (Peto OR 1.22, 95% CI 0.50 to 2.94; 5 studies (2 studies with 2 intervention arms), 855 participants; very low-certainty evidence). Home-based education results in little to no difference in exacerbations requiring a course of oral corticosteroids compared to control (mean difference (MD) -0.18, 95% CI -0.63 to 0.26; 1 study (2 intervention arms), 250 participants; low-certainty evidence). Secondary outcomes Home-based education may improve quality-of-life scores compared to control, but the evidence is very uncertain (standardised mean difference (SMD) 0.32, 95% CI 0.08 to 0.56; 4 studies, 987 participants; very low-certainty evidence). The evidence is very uncertain about the effects of home-based education on mean symptom-free days, days missed from school/work and exacerbations leading to hospitalisation compared to control (all very low-certainty evidence). Home-based education versus less-intensive home-based education for children with asthma Primary outcomes A more-intensive home-based education intervention did not reduce exacerbations leading to emergency department visits (Peto OR 1.36, 95% CI 0.35 to 5.30; 4 studies, 729 participants; low-certainty evidence) or exacerbations requiring a course of oral corticosteroids (MD 0.08, 95% CI -0.14 to 0.30; 3 studies, 605 participants; low-certainty evidence), compared to a less-intensive type of home-based education. Secondary outcomes A more-intensive home-based asthma education intervention may reduce hospitalisation due to an asthma exacerbation (Peto OR 0.14, 95% CI 0.04 to 0.55; 4 studies, 689 participants; low-certainty evidence), but not days missed from school (low-certainty evidence), compared with a less-intensive home-based asthma education intervention. A more intensive home-based education intervention had no effect on quality of life and symptom-free days (both very low certainty), compared with a less-intensive home-based asthma education intervention, but the evidence is very uncertain.

AUTHORS' CONCLUSIONS

We found uncertain evidence for home-based asthma educational interventions compared to usual care, education delivered outside the home or a less-intensive educational intervention. Home-based education may improve quality of life compared to control and reduce the odds of hospitalisation compared to less-intensive educational intervention. Although asthma education is recommended in guidelines, the considerable diversity in the studies makes the evidence difficult to interpret about whether home-based education is superior to none, or education delivered in another setting. This review contributes limited information on the fundamental optimum content and setting for educational interventions in children. Further studies should use standard outcomes from this review and design trials to determine what components of an education programme are most important.

Non-clinical Psychosocial Mental Health Support Programmes for People with Diverse Language and Cultural Backgrounds: A Critical Rapid Review

Low accessibility to mainstream psychosocial services disadvantages culturally and linguistically diverse (CALD) populations, resulting in delayed care and high rates of unsupported psychological distress. Non-clinical interventions may play an important role in improving accessibility to psychosocial support, but what characterises best practice in this space remains unclear. This critical rapid review addressed this gap by searching for, and critically analysing, existing research on non-clinical psychosocial support services, drawing from a critical realist framework and Brossard and Chandler's (Brossard and Chandler, Explaining mental illness: Sociological perspectives, Bristol University Press, 2022) taxonomy of positions on culture and mental health. We searched PubMed, PsycInfo, LILACS, Scopus and Sociological Abstracts to identify non-clinical psychosocial support interventions for first-generation immigrant CALD populations delivered by lay-health workers. Thirty-eight studies were included: 10 quantitative, 7 mixed-methods and 21 qualitative. Most studies were conducted in North America (n = 19) and Europe (n = 7), with few conducted in low-income countries (Tanzania and Lebanon, n = 3 each, Kenya [n = 1]). Studies often focussed on specific interventions (e.g. psychoeducation) for targeted populations (e.g. refugees, Latinx immigrants); multimodal interventions (e.g. psychological support and food distribution) for broad populations were less common. Thirty-five different outcome scales were identified across quantitative and mixed-methods studies, with most covering depression, stress and trauma. Most studies identified significant improvements for at least one psychosocial outcome despite interventions being relatively short in sessions. Findings from qualitative studies highlighted varied engagement with theory-informed models of service, and identified important barriers to non-clinical psychosocial support services, including precarious resourcing. Our analysis suggests most studies were underpinned by split-relativist frameworks and focussed on interventions aimed at helping clients navigate the eurocentricity and complexity of mainstream services. Recognising the eurocentrism of universalist frameworks, working from a culturally relativist position, prioritising social determinants of health and using models that centre clients, flexibility, context, culture and community are likely to ensure best practice for non-clinical psychosocial support interventions.

Effectiveness of psychosocial interventions for improving asthma symptoms and parental stress in families of school-age children with asthma: A systematic review and meta-analysis

BACKGROUND

Asthma is a prevalent chronic disease affecting school-age children, with substantial psychosocial implications for children and their parents.

OBJECTIVES

This review aimed to synthesise current evidence on the effects of psychosocial interventions for families of school-age children with asthma and investigate the optimal features of effective interventions.

METHODS

Embase, MEDLINE, PsycINFO, CINAHL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Google Scholar, CNKI, and Wanfang Data were searched from inception to November 2023. Randomised controlled trials (RCTs) examining psychosocial interventions in children aged six to twelve with asthma on asthma symptoms and parental stress were included. Emergency department visits, hospitalisations, lung function, psychological symptoms and health-related quality of life in both children and parents were secondary outcomes. Data were pooled for short-term (≤ three months), medium-term (> three months and ≤ six months), and long-term (> six months) follow-ups. Risk of bias was appraised using version 2 of the Cochrane risk of bias tool for randomised trials. Meta-analysis was performed using RevMan 5.4.1.

RESULTS

Seven RCTs with 884 parent-child dyads from two countries were included. Meta-analyses found that psychosocial interventions improved asthma control (k = 2, n = 301, standardised mean difference [SMD] 0.35, 95 % confidence interval [CI] 0.12 to 0.58, P = 0.003), sleep problem (k = 2, n = 149, SMD -0.47, 95 % CI -0.79 to -0.14, P = 0.005), cough (k = 2, n = 149, SMD -0.97, 95 % CI -1.59 to -0.35, P = 0.002), wheezing (k = 2, n = 149, SMD -0.76, 95 % CI -1.09 to -0.42, P < 0.0001), and parental stress (k = 6, n = 813, SMD -0.32, 95 % CI -0.61 to -0.02, P = 0.03), compared to controls in the short term. Subgroup analysis revealed significant effects of psychoeducation, family empowerment interventions, and acceptance and commitment therapy-based interventions on reducing parental stress. No significant intervention effects were observed on parental symptoms of depression at any follow-up. Narrative synthesis indicated that psychosocial interventions may provide benefits in children's health-related quality of life in the short term, parental symptoms of anxiety in the medium term, and activity limitation, cough, and wheezing in the long term. The intervention effects for other reviewed outcomes were inconsistent.

CONCLUSIONS

Psychosocial interventions demonstrate possible benefits for families of school-aged children with asthma in asthma symptoms, parental stress, and children's health-related quality of life within three months post-intervention and parental symptoms of anxiety at six months post-intervention. Future research with rigorous design should investigate the optimal duration, frequency, and intervention approaches of psychosocial interventions.

TWEETABLE ABSTRACT

Psychosocial interventions improve asthma symptoms and parental stress within three months post-intervention for families of school-age children with asthma @ConnieChong1.

Patient navigator programmes for children and adolescents with chronic diseases

BACKGROUND

Despite a substantial global improvement in infant and child mortality from communicable diseases since the early 1990s there is now a growing burden of chronic disease in children and adolescents worldwide, mimicking the trend seen in the adult population. Chronic diseases in children and adolescents can affect all aspects of their well-being and function with these burdens and their health-related consequences often carried into adulthood. Up to one third of disability-adjusted life years for children and adolescents globally are a result of chronic disease. This has profound implications for the broader family unit, communities, and health systems in which these children and young people reside. Models of chronic care delivery for children and adolescents with chronic disease have traditionally been adapted from adult models. There is a growing recognition that children and adolescents with chronic diseases have a unique set of healthcare needs. Their needs extend beyond disease education and management appropriate to the developmental stage of the child, to encompass psychological well-being for the entire family and a holistic care approach focusing on the social determinants of health. It is for this reason that patient navigators have been proposed as a potential intervention to help fulfil this critical healthcare gap. Patient navigators are trained medical or non-medical personnel (e.g. lay health workers, community health workers, nurses, or people with lived experience) who provide guidance for the patients (and their primary caregivers) as they move through complex (and often bewildering) medical and social systems. The navigator may deliver education, help to co-ordinate patient care, be an advocate for the patient (and their primary caregivers), or combinations of these. Patient navigators can assist people with a chronic illness (especially those who are vulnerable or from a marginalised population, or both) to better understand their diagnoses, treatment options, and available resources. As there is considerable variation in the purpose, design, and target population of patient navigator programmes, there is a need to systematically review and summarise the existing literature on the effectiveness of navigator programmes in children and young adults with chronic disease.

OBJECTIVES

To assess the effectiveness of patient navigator programmes in children and adolescents with chronic diseases.

SEARCH METHODS

We searched the Cochrane Library and Epistemonikos up to 20 January 2023 for related systematic reviews using search terms relevant to this review. We searched CENTRAL, MEDLINE, Embase, CINAHL EBSCO, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov for primary studies.

SELECTION CRITERIA

We included randomised controlled trials reporting the effect of patient navigator interventions on children and adolescents (aged 18 years or younger) with any chronic disease in hospital or community settings. Two review authors independently assessed the retrieved titles and abstracts, and where necessary, the full text to identify studies that satisfied the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data using a standard data extraction form. We used a random-effects model to perform a quantitative synthesis of the data. We used the I² statistic to measure heterogeneity amongst the studies in each analysis. We indicated summary estimates as mean differences (MD), where studies used the same scale, or standardised mean differences (SMD), where studies used different scales, with 95% confidence intervals (CI). We used subgroup and univariate meta-regression to assess reasons for between-study differences. We used the Cochrane RoB 1 tool to assess the methodological quality of the included studies. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 17 studies (2895 randomised participants). All studies compared patient navigators with standard care. Most studies were at unclear or high risk of bias. Meta-analysis was undertaken only for those studies that had the same duration of patient navigator intervention and follow-up/reporting of outcome measures. The evidence is very uncertain about the effects of patient navigator programmes compared with standard care on self-reported quality of life of children with chronic illness (SMD 0.63, 95% CI -0.20 to 1.47; I2 = 96%; 4 studies, 671 participants; very low-certainty evidence); parent proxy-reported quality of life (SMD 0.09, 95% CI -2.21 to 2.40; I2 = 99%; 2 studies, 309 participants; very low-certainty evidence); or parents' or caregivers' quality of life (SMD -1.98, 95% CI -4.13 to 0.17; I2 = 99%; 3 studies, 757 participants; very low-certainty evidence). It is uncertain whether duration of patient navigator intervention accounts for any of the variances in the changes in quality of life. The evidence is very uncertain about the effects of patient navigator programmes compared with standard care on the number of hospital admissions (MD -0.05, 95% CI -0.34 to 0.23; I2 = 99%; 2 studies, 381 participants; very low-certainty evidence) and the number of presentations to the emergency department (MD 0.06, 95% CI -0.23 to 0.34; I2 = 98%; 2 studies, 381 participants; very low-certainty evidence). Furthermore, it is unclear whether patient navigator programmes reduce the number of missed school days as data were sparse (2 studies, 301 participants). Four studies (629 participants) reported data on resource use. However, given the variation in units of analysis used, meta-analysis was not possible (very low-certainty evidence). All studies reported cost savings or quality-adjusted life year improvement (or both) in the patient navigation arm. No studies reported on adverse events (specifically, abuse of any type against the navigator, the patient, or their family members).

AUTHORS' CONCLUSIONS

There is insufficient evidence at present to support the use of patient navigator programmes for children and adolescents with chronic diseases. The current evidence is based on limited data with very low-certainty evidence. Further studies are likely to significantly change these results.

The effect of mobile game training designed for asthmatic children on asthma management and quality of life

PURPOSE

This study aimed to examine the effect of mobile game training designed for children with asthma on inhaler use skills, asthma symptoms and treatment needs, and quality of life.

DESIGN AND METHODS

This randomized controlled study was conducted between April and October 2023 at "Pediatric Asthma and Allergy Clinic" in Turkey. The sample of the study consists of a total of 74 children diagnosed with asthma, including the Mobile game (n: 37) and the Control group (n: 37). In the study, a mobile game was developed for children with asthma between the ages of 8-12. In collecting research data; Child and Parent Information Form, Inhaler Use Skill Evaluation Form, Asthma Symptom and Treatment Need Scoring (Asthma Symptom Score [ASS], Rhinitis Symptom Score [RSS] and Total Symptom Score [TSS]), DISABKIDS Asthma Scale were used.

RESULTS

There was no significant difference between the groups in terms of the demographic status of the children (p > 0.05). It was determined that the average inhaler use skill score and DISABKIDS asthma scale Child/Parent score average of the children in the mobile game group were higher than the control group (p < 0.05). When the children's final follow-up ASS, RSS and TSS total scores were examined; It was determined that there was a statistically significant difference between the children in the mobile game and control groups (p < 0.05).

CONCLUSIONS

As a result of this study, it was determined that mobile game training designed for children is an effective method in increasing children's ability to use inhaler medications, reducing asthma symptoms and treatment needs, and improving quality of life.

PRACTICE IMPLICATION

Nurses can improve children's quality of life by using mobile game training programs that attract children's attention.

Effectiveness of community-based family-focused interventions on family functioning among families of children with chronic health conditions: A systematic review and meta-analysis

Community-based family-focused interventions can offer support to families of children with chronic health conditions. This review aimed to evaluate the effectiveness of community-based family-focused interventions in improving family functioning, disease knowledge, and child health outcomes among families of children with chronic health conditions. Eight electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL, PsycINFO, Scopus, Web of Science, and ProQuest Dissertations & Theses Global) and one trial registry (ClinicalTrials.gov) were searched from their dates of inception to October 2022. Meta-analysis was performed under the random-effect model when appropriate otherwise, findings were narratively synthesized. I2 statistics and Cochran's Q chi-squared test were used to determine heterogeneity. Quality appraisal was conducted by the Cochrane risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation approach at the study and outcome level, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines guided this review. Eight studies were included in this review. Community-based family-focused interventions were viable methods that could support families of children with chronic health conditions. Family-focused interventions that incorporate guided role-playing exercises for parents and children, psychoeducational components, and elements from relationship-focused interventions could support families more effectively. However, current findings are mostly limited to interventions conducted in patients' homes, and the long-term effect of these interventions cannot be determined. Overall, community-based family-focused interventions have the potential to offer valuable support to families of children with chronic health conditions, and future research could seek to improve the effectiveness of these interventions.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers

BACKGROUND

The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children.

OBJECTIVES

Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention.

METHODS

Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes.

RESULTS

Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms.

CONCLUSIONS

The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

Meaningful Change and Treatment Responsivity in Intervention Research: A Targeted Review of Studies Published in the Journal of Pediatric Psychology

OBJECTIVE

Randomized-controlled trials (RCTs) in pediatric psychology form the foundation for evidence-based treatment and best practices in the field. Relying heavily on continuous outcome measures and group comparisons, questions concerning meaningful clinical change and treatment response rates remain open. This targeted review aimed to provide an initial description of the current state of intervention research in pediatric psychology in terms of attention to meaningful clinical change and efforts to assess and characterize participants in terms of treatment responsivity.

METHODS

Online databases were used to identify a sample of RCT published in the Journal of Pediatric Psychology from 2010 to 2021 using the term "randomized" in the title. Using predefined eligibility and exclusion criteria, 43 studies were identified and analyzed with regard to characteristics of intervention, population, measurement, data reporting, and reference to indicators of clinical significance, meaningful change, treatment responsivity rates, and predictors.

RESULTS

26 studies (60%) made no reference at all to meaningful clinical change, treatment response criteria and rates, or characteristics of treatment responders. 15 studies (35%) reported measures of meaningful change in their interpretation of group differences, to calculate sample size, in relation to baseline data only, or in describing a measure. 2 studies (5%) reported criteria for assessing meaningful change to determine individual response rates and characteristics of responders.

CONCLUSIONS

These findings highlight the need for greater emphasis on defining standards and analyzing treatment outcome research in terms of metrics of meaningful change and treatment response in order to better target intervention and optimize limited resources.

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.