Decision-making in children with asthma and their parents

Caregiver experiences helping children with Down syndrome use positive airway pressure to treat obstructive sleep apnea

BACKGROUND/OBJECTIVE

While positive airway pressure (PAP) is an efficacious intervention for the treatment of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS), implementation and consistent use can be difficult. Caregiver perspectives and experiences using PAP are described with the aim of informing clinical practice.

METHODS

Qualitative semi-structured phone interviews were conducted with 40 caregivers (i.e., mothers) of children with DS and OSAS treated with PAP for at least 6 months. Content analysis was used to identify themes associated with adherence and non-adherence.

RESULTS

Respondents indicated variability in caregiver experience with the adoption of PAP and observed benefits of PAP. Varied experiences were attributed to several themes including accessing supplies, interactions with the medical team and equipment company, and patients' unique needs and behaviors, including the child's willingness and ability to adapt to PAP, sensory sensitivities, keeping the mask on all night, and differences in daytime behavior. Many families reported that desensitization with a reward system and trust within the caregiver-patient relationship were helpful. Caregiver suggestions for improving PAP adherence for families of children with DS included improving communication with the medical team and medical equipment company, emphasizing patience, using visual supports, and social support and education for extended family.

CONCLUSIONS

Although family experiences varied, several actionable strategies by both the medical team and families emerged for improving the experience of and adherence to PAP in children with DS.

Continuous positive airway pressure care for pediatric obstructive sleep apnea: A long-term quality improvement initiative

Successful treatment of pediatric obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) is challenging due to behavioral, technical, medical, and systems factors. We undertook a quality improvement (QI) initiative involving physicians, nurses, psychologists, and respiratory therapists to improve CPAP outpatient care and processes. We aimed to: (1) increase the proportion of patients with a follow-up visit within 4 months of initiation of CPAP, (2) reduce the median time to first follow-up visit to under 4 months, and (3) increase the proportion of patients obtaining a post-initiation polysomnogram within 1 year to >50%. We also explored healthcare utilization (HCU) in a subsample of patients. Interventions focused on developing a tracking system and standardizing interdisciplinary clinical care. The proportion of patients returning to clinic within 4 months improved from 38.2% to 65.5% and median time to first follow-up visit improved from 133 to 56 days. The percentage of patients who returned for a post-initiation polysomnogram within 1 year was 71.1%. Subsample analyses showed significant reductions in the length of stay for emergency department visits from pre-CPAP initiation (Mdn = 3.00 h; interquartile range [IQR] = 7.00) to post-initiation (Mdn = 2.00 h, IQR = 5.00). The length of hospitalizations was also significantly shorter from pre (Mdn = 48.00 h, IQR = 243.00) to post-CPAP initiation (Mdn = 0.00 h, IQR = 73.00). A standardized, tracked approach to interdisciplinary outpatient CPAP care can improve follow-up care and potentially HCU.

Parents’ Decision Making During Their Child’s Asthma Attack: Qualitative Systematic Review

Objective

To conduct a systematic review and synthesis of qualitative evidence exploring the factors that influence a parent’s decision to seek medical assistance while their child is having an asthma attack.

Methods

Studies were included if they used qualitative methodologies and explored parent or carers’ experience of caring for a child (2 to 12 years) during an acute asthma attack at home or in the community. We searched MEDLINE (OVID interface, 1948 onwards), EMBASE (OVID interface, 1980 onwards) and CINAHL (EBSCO) electronic databases. Quality appraisal was assessed by the Critical Appraisal Skills Program CASP for qualitative research, and the qualitative studies in this review were analyzed by thematic synthesis.

Results

From 4798 identified studies, 17 met the inclusion criteria. Synthesis revealed two distinct processes used by parents to aid their decision to seek medical intervention for their child. The first, past experiences informing future decisions and secondly facilitators that drive parents’ to actively pursue medical help.

Conclusion

This review highlights the importance of providing asthma education that not only focuses on the provision of information on symptoms, triggers, medication, and device use but asthma education that targets parents’ unique experience. Using a family strength approach education can impact parents’ future behavior when deciding to seek medical assistance for their child when experiencing an asthma attack. There was not a specific funding source, which supported this review. This review was registered with PROSPERO Identification Number CRD4201912740.

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.

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84 studies reviewed and analyzed using the convergent integrated approach

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

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

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

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Interventions and knowledge translation strategies must be developed with parents

Decision Making in Pediatric Plastic Surgery: Autonomy and Shared Approaches

BACKGROUND

Although shared decision-making is essential to patient-centered healthcare, its role in pediatric plastic surgery remains unclear. The objective of this study was to define the preferred level of involvement in surgical decision-making among children, caregivers, and surgeons.

METHODS

The authors surveyed pediatric plastic surgery patients (n = 100) and their caregivers regarding their preferences on child involvement during surgical decision-making. Fleiss' kappa was used to assess agreement between groups. Bivariate Chi-square tests and multinomial logistic regression were used to assess the relationship between decision-making preferences and select demographic factors.

RESULTS

Only 34% of children and their caregivers agreed upon their decision-making preferences (k = 0.04). The majority of children (40%) and caregivers (67%) favored shared decision-making between the patient, caregiver, and surgeon. Only 16% of children preferred physician-driven decisions, while 20% of children desired complete autonomy. Children's preferences were significantly associated with their age; the relative risk of children deferring to caregivers or surgeons over a shared approach was lower for adolescents and teens compared to children under 10 years old (relative risk = 0.20; 95% confidence interval: 0.054-0.751; P = 0.02). Caregiver's preferences did not change based on the child's age, but rather were related to the child's gender. Caregivers were more likely to choose the option that gave the child more autonomy when the child was male.

CONCLUSIONS

While most caregivers preferred a shared approach to decision-making, children desired greater autonomy, particularly with increasing age. Since there was limited agreement between caregivers and children, surgeons must be cognizant of differing preferences when discussing treatment plans to optimize both patient and parent satisfaction.

Experiences of parents and carers in managing asthma in children: a qualitative systematic review

OBJECTIVE

The objective of the review was to identify, critically appraise and synthesize the best available qualitative evidence to understand the lived experiences of parents and carers caring for a child aged 0-18 years with asthma in any setting and managing their condition.

INTRODUCTION

Asthma affects around 14% of children and despite the availability of effective therapies, asthma control is suboptimal and hospitalization rates remain high. Mothers predominantly manage their child's asthma and experience stress and exhaustion due to complex treatments and balancing work and family life. This review provides an understanding of the barriers parents and carers face in managing their child's asthma and highlights the needs of families throughout their asthma journey.

INCLUSION CRITERIA

The review considered qualitative studies examining the experiences of parents and carers caring for a child with asthma, wheeze or bronchiolitis and managing their condition. Research designs included, but were not limited to, phenomenology, grounded theory, ethnography, and action and feminist research.

METHODS

A comprehensive search using PubMed, CINAHL, Embase, PsycINFO, Web of Science and ProQuest for published and unpublished studies was undertaken in June 2017 and December 2017. Studies published in English from 1972 to 2017 were included. The recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used.

RESULTS

Seventy-seven qualitative studies were included in this review, including grounded theory, phenomenology and ethnography methodologies. From these 77 studies, 1655 participants from a variety of cultural backgrounds and socio-economic status groups were represented. The methodological quality of included articles was sound and participants' voices were strong. A total of 1161 findings (966 unequivocal and 195 credible) were extracted and grouped into 41 categories, based on similarity in meaning. From the 41 categories, seven synthesized statements were produced: i) Negotiating the meaning of having a child with asthma, ii) Impact on family life, iii) The process of getting a diagnosis and learning about asthma, iv) Relationships with healthcare professionals and the emergency department experience, v) Medication beliefs, concerns and management strategies, vi) With time, parents and carers become more comfortable managing their child's asthma, vii) The need for support.

CONCLUSIONS

This review highlights the difficulties parents and carers face when caring for a child with asthma and managing their child's condition. Attaining a definitive diagnosis of asthma can be challenging, and parents and carers express uncertainty and fear due to continuing symptoms and repeated hospitalizations. Healthcare professionals should ensure that a clear diagnostic strategy and treatment plan are communicated so parents and carers have an understanding of the pathway to receiving an actual diagnosis. Comprehensive asthma education is essential at the onset of asthma symptoms, with accurate, easy to understand and culturally relevant information. Supportive relationships, with healthcare professionals taking a partnership approach, ensuring adequate time, continuity of care, regular follow-up, and addressing the psychosocial and cultural needs and concerns of parents and carers, are recommended. Support groups and training for education staff is imperative to ensure they can support parents and carers, provide asthma friendly environments and respond appropriately in an asthma emergency.

Shared decision-making in older children and parents considering elective adenotonsillectomy

OBJECTIVES

Shared decision-making describes a collaborative process in which healthcare providers and patients/families make treatment decisions using the best available evidence, while taking into account the patient's values and preferences. The objectives of this study were to assess the level of decisional conflict and shared decision-making experienced by older children and their parents when considering elective adentonsillectomies.

DESIGN

A prospective cohort study.

SETTING

Paediatric otolaryngology clinic in a teaching hospital.

PARTICIPANTS

Participants included 53 children older than 9 years and their parents who underwent consultation for tonsillectomy with or without adenoidectomy.

MAIN OUTCOMES MEASURES

Children and parents completed the Decisional Conflict Scale (DCS) and Shared Decision-Making Questionnaire-Patient Version (SDM-Q-9). Surgeons completed the Shared Decision-Making Questionnaire-Physician Version (SDM-Q-Doc).

RESULTS

Overall, 10 (19%) parents and 18 (34%) children reported clinically significant decisional conflict. Parents who opted not to proceed with surgery had significantly higher DCS scores than those who decided to proceed with surgery. Both parents and children SDM-Q-9 and total DCS scores were significantly negatively correlated. Physician SDM-Q-Doc and parent total DCS scores were negatively correlated, while parent and physician SDM scores were positively correlated.

CONCLUSIONS

Many older children and parents reported significant decisional conflict when considering elective paediatric otolaryngology surgery. Decisional conflict levels for both children and parents decreased with greater perceived levels of shared decision-making. Older children did not appear to discern the same levels of shared decision-making as parents and surgeons. Future research should assess methods to implement shared decision-making into clinical practice for clinicians, parents and children when appropriate.

Shared clinician-patient decision-making about treatment of pediatric asthma: what do we know and how can we use it?

PURPOSE OF REVIEW

Shared decision-making (SDM) is an emerging field that promises to improve healthcare. We aim to explore the concept of SDM, how it has been studied or applied in the treatment of asthma, and how it might be implemented to improve adherence and outcomes in pediatric asthma.

RECENT FINDINGS

Healthcare providers often fail to involve their patients in clinical decision-making by not presenting all available options, associated risks and benefits, in light of the patient's values, preferences, concerns, lifestyle, and perceived barriers to following various treatment regimens. It has been argued that SDM is preferable to a clinician-controlled approach and may improve patient outcomes (increase satisfaction with care, reduce decisional conflict and decisional regret, improve health-related quality of life, and increase decision-specific knowledge). This may be especially important in managing chronic conditions in which adherence to treatment regimen may increase if the patient was actively involved in the decision-making. In pediatrics, the decision process is further complicated by the clinician-parent(s)-child interaction. We found no studies on how to effectively involve and communicate with children at different developmental levels, or how to coalesce the parent and child's perspective to work as a unit.

SUMMARY

SDM has the promise to improve satisfaction with disease management, treatment adherence and patient-centered outcomes in pediatric asthma, but further research is needed to determine its effectiveness and to establish guidelines on how to implement SDM in the clinical setting and incorporate the input and preferences of all stakeholders' perspectives.

The information needs of North American parents of children with asthma: a state-of-the-science review of the literature

INTRODUCTION

Asthma, the most common chronic disease of childhood, presents diverse challenges to parents who are responsible for its management. Parents must be informed regarding symptom recognition, medications, prevention, and treatment to effectively minimize acute exacerbations and asthma sequela. Current approaches to asthma education do not address the vast range of information needs of parents, and few studies explicitly identify parental information needs in a comprehensive manner. To address this gap and to create a parental information needs taxonomy, a "state-of-the-science" review of the literature was conducted.

METHOD

Three electronic databases were searched and articles were screened according to pre-established inclusion criteria.

RESULTS

Of 164 articles retrieved, 11 articles met the inclusion criteria and were included in the review.

DISCUSSION

Parental information needs can be classified in the following categories: asthma basics, treatment modalities, coping, and medical expectations. This information needs taxonomy may help practitioners better address the information needs of parents of children with asthma.

Asthma knowledge, subjective assessment of severity and symptom perception in parents of children with asthma

OBJECTIVES

This study aimed to confirm the tendency for parents to underestimate the severity of symptoms and the poor consistency between parents' reports of symptoms and the physicians' evaluation of asthma control. Additionally, the relationship between parents' asthma knowledge and their report of symptoms and estimation of asthma severity was explored.

METHODS

Fifty children (M = 10.5 years) and their caregivers were recruited from two Portuguese hospitals. A measure of asthma symptoms report (Severity of Chronic Asthma, SCA) and a subjective evaluation of asthma severity were collected and compared with physicians' ratings of asthma control, as well as parents' knowledge about asthma (Asthma Knowledge Questionnaire, AKQ) and emotional disturbance (Brief Symptom Inventory, BSI).

RESULTS

Although parents' evaluation of perceived asthma severity was moderately correlated to symptoms reported, results confirm an inconsistency between parents' reports of symptoms, their subjective rating of asthma severity and the physician's rating of clinical control, revealing a tendency for parents to underestimate disease severity and to underreport asthma symptoms. Asthma knowledge was not significantly correlated to SCA or to parents' subjective evaluation of asthma severity. Parents with poorer knowledge reported fewer symptoms.

CONCLUSIONS

Portuguese parents revealed a tendency to overestimate their child's level of asthma control and a low level of asthma knowledge. Parents' education, psychological disturbance and time since diagnosis were associated with asthma knowledge. Parents' knowledge was not related to the child's asthma outcomes or to their subjective evaluation of asthma severity or symptoms reports. Parents' asthma knowledge deficits, underreporting of symptoms and underestimation of asthma severity, may affect parent-provider communication and impede asthma control.

Developing an interactive story for children with asthma

Despite advancements in asthma treatment and diagnosis, asthma still remains the number 1 cause for hospitalizations in school-aged children. This usability study aimed to develop a child-friendly interactive narrative, Okay with Asthma v2.0, based on the Biopsychosocial Family Model using feedback from children. This fun and kid-friendly program encourages children to manage their own asthma with the help of peers, families, communities, and health care services. With these support structures, children can identify and avoid triggers, monitor their asthma, manage their condition with medications based on an action plan, and learn to live happily with asthma.

Ethical aspects of children's perceptions of information-giving in care

The aim of this study was to identify key aspects in the exchange of information and to determine how nurses communicate news to hospitalised children. For this study, we applied the critical incident technique with 30 children aged between 8 and 14 years. Data were collected in paediatric units in a hospital in Alicante (Spain) using participant observation and semi-structured interviews. The analysis yielded three main categories: the children's reaction to the information, nursing staff behaviour as a key aspect in the exchange of information and communication of news as well as children's experience. This article emphasises the need to promote children's consent and participation in nursing interventions. An analysis of these aspects will verify whether children's rights are being respected and taken into account in order to promote children's well-being and adaptation to hospitalisation.

Children's participation in decision-making: balancing protection with shared decision-making using a situational perspective

Children's participation in decision-making in the health care setting is complex because parents and health professionals tend to take a protective stance towards children to act in their best interest. Children prefer to be protected in some situations and to share decision-making in others. Adults in the health care setting need to consider children as individuals, rather than as a homogenous group, and take into account that a child's competence and preferences will depend on the circumstances in every situation. This article argues for a situational perspective of children's participation to act in the child's best interest and to balance protection with shared decision-making, according to children's rights and desires.

Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature

OBJECTIVE

To understand better what helps and/or hinders asthma action plan use from the professionals and patients/carers perspective.

METHODS

Systematic review and qualitative synthesis (using meta-ethnography).

RESULTS

Nineteen studies (20 papers) were included in an analysis of patients/carers' and professionals' views. Seven main influences on action plan implementation were identified including perceived un-helpfulness and irrelevance of the plans. Translation and synthesis of the original authors' interpretations suggested that action plan promotion and use was influenced by professional and patient/carers' asthma beliefs and attitudes and patient/carer experiences of managing asthma. Action plan use is hindered because professionals and patients/carers have different explanatory models of asthma, its management and their respective roles in the management process. Patients/carers, based on their experiential knowledge of their condition, perceive themselves as capable, effective in managing their asthma, but health professionals do not always share this view.

CONCLUSION

Professionally provided medically focused action plans that do not 'fit' with and incorporate the patients'/carers' views of asthma, and their management strategies, will continue to be under-utilised.

PRACTICE IMPLICATIONS

Professionals need to develop a more patient-centred, partnership-based, approach to the joint development and review of action plans, recognising the experiential asthma knowledge of patients/carers.

Adolescent decision-making about use of inhaled asthma controller medication: results from focus groups with participants from a prior longitudinal study

BACKGROUND

Adherence with inhaled controller medications for asthma is known to be highly variable with many patients taking fewer doses than recommended for consistent control of lung inflammation. Adherence also worsens as children become teenagers, although the exact causes are not well established.

OBJECTIVE

To use focus group methodology to examine beliefs, feelings, and behaviors about inhaled asthma controller medication in adolescents and young adults who had previously participated in a longitudinal study of asthma treatment adherence and outcome in order to develop more effective management strategies.

METHODS

Twenty-six subjects participated in 6 focus groups comprised of 3-5 young adults (age range 12-20 years). Verbatim transcripts of these groups were analyzed using the long-table method of content analysis to identify key themes raised by participants.

RESULTS

A variety of beliefs, feelings, and behaviors influence the adolescent's decision about how to use their asthma medication. Some of the adolescents understood the importance of daily medication and were committed to the treatment plan prescribed by their provider. Poorer adherence was the product of misinformation, incorrect assumptions about their asthma, and current life situations.

CONCLUSIONS

These results, by highlighting potential mechanisms underlying both better and worse adherence, inform the development of strategies to improve adherence behavior in adolescents and young adults with asthma. Knowledge of the specific beliefs, feelings, and behaviors that underlie adolescents' use of inhaled asthma controller medication will help providers maximize treatment adherence in this notoriously difficult patient population.

What is known about parents' treatment decisions? A narrative review of pediatric decision making

BACKGROUND

With the increasing complexity of decisions in pediatric medicine, there is a growing need to understand the pediatric decision-making process.

OBJECTIVE

To conduct a narrative review of the current research on parent decision making about pediatric treatments and identify areas in need of further investigation.

METHODS

Articles presenting original research on parent decision making were identified from MEDLINE (1966-6/2011), using the terms "decision making," "parent," and "child." We included papers focused on treatment decisions but excluded those focused on information disclosure to children, vaccination, and research participation decisions.

RESULTS

We found 55 papers describing 52 distinct studies, the majority being descriptive, qualitative studies of the decision-making process, with very limited assessment of decision outcomes. Although parents' preferences for degree of participation in pediatric decision making vary, most are interested in sharing the decision with the provider. In addition to the provider, parents are influenced in their decision making by changes in their child's health status, other community members, prior knowledge, and personal factors, such as emotions and faith. Parents struggle to balance these influences as well as to know when to include their child in decision making.

CONCLUSIONS

Current research demonstrates a diversity of influences on parent decision making and parent decision preferences; however, little is known about decision outcomes or interventions to improve outcomes. Further investigation, using prospective methods, is needed in order to understand how to support parents through the difficult treatment decisions.

Levers and barriers to patient-centred care with children: findings from a synthesis of studies of the experiences of children living with type 1 diabetes or asthma

BACKGROUND

The last 50 years have seen a sea change in approaches to health care with children, from a time when children were routinely separated from parents while in hospital, to current recognition of the importance of placing the experiences of children and their families at the heart of care. Yet, there is a gap in the evidence about how children's involvement might be best achieved.This study aimed to synthesize findings of children's experiences of long-term illness and, from this, to identify levers and barriers to patient-centred care with children.

METHODS

A synthesis of studies of the experiences of children living with type 1 diabetes or asthma.

DATA SOURCES

Eight health and social care databases, bibliography searches and consultation with field experts and first authors of included studies.

ELIGIBILITY CRITERIA

Qualitative studies with children 10 years (mean) and younger on their experiences of living with type 1 diabetes or asthma.

MAIN RESULTS

Findings suggest key 'levers' to patient-centred care with children include: (1) engagement with children's expertise about their own lives: their personal and social experiences of their care, including how these are affected by their relative lack of power in some settings; (2) exploring children's understandings and preferences in terms of their physical sensations and day-to-day experiences; (3) willingness to find resources to engage with even the youngest children; (4) avoiding age-based assumptions about children's contributions to their care.

DISCUSSION AND CONCLUSIONS

Action on the above 'levers' may present a range of challenges in healthcare settings not least because it represents a move away from medicine's historical focus on children's developing competencies to engage rather with children's social realities from the earliest ages.

African American parents'/guardians' health literacy and self-efficacy and their child's level of asthma control

Nearly 1 of 10 American children has asthma. Asthma is addressed in Healthy People 2010 as a public health problem. This study examined the relationship between parents'/guardians' health literacy levels and their perceived self-efficacy to manage their child's asthma. A four-page asthma questionnaire was developed to assess the self-efficacy of parents/guardians of African American children with asthma. There was a statistically significant relationship among the parents'/guardians health literacy levels and their perceived efficacy expectations to manage their child's asthma. There is evidence that high parental/guardian self-efficacy and successful asthma management contribute to a child with well-controlled asthma. It is necessary for patient educators to capitalize on physician/nurse visits and use the time for asthma education, particularly to increase the efficacy expectations of parents/guardians with limited health literacy skills.

The role of parents in managing asthma in middle childhood: an important consideration in chronic care

Asthma is a significant illness for Australian children and their families. In childhood, parents have the primary responsibility for managing asthma on a day-to-day basis, and therefore understanding the management of asthma by parents is important to nursing practice. Middle childhood (5-12 years) is an important time in the lives of children and families with asthma, as children commence school and spend increasing amounts of time away from direct parental care. In order to manage asthma during middle childhood, parents need to understand asthma as an illness, understand the treatment of asthma, be able to monitor and respond to changes in condition, manage other carers, manage asthma in the context of family life and guide the development of self-management responsibility in their child with asthma. While the scope of parent management in terms of asthma knowledge and treatment has been well explored in the literature, less is known about the process by which parents support the development of self-management responsibility in children with asthma.

Influences on adherence to pediatric asthma treatment: a review of correlates and predictors

Nonadherence to treatment is an important influence on the health outcomes of children and adolescents with pediatric asthma, which is the most prevalent childhood chronic illness. Because the factors that influence treatment adherence for pediatric asthma are not well understood, a comprehensive review of relevant research is needed. To address this need, research concerning the correlates and predictors of adherence to inhaled corticosteroid treatment for pediatric asthma was reviewed. Significant predictors and correlates of treatment adherence identified in this review were consistent with a conceptual model that included family demographic characteristics and functioning, parent and child characteristics, health care system and provider characteristics, and child health outcomes. Family functioning and parental beliefs about asthma and medication treatment demonstrated consistent relationships with treatment adherence. Future research should test multivariate models of influences on treatment adherence in pediatric asthma in prospective studies using reliable and valid measures of predictors and outcomes. Intervention studies are also needed that target potentially modifiable, empirically supported influences to enhance treatment adherence. The clinical management of pediatric asthma would be enhanced by routine assessment of barriers to treatment adherence and anticipatory interventions that address them to prevent nonadherence.

What affects asthma medicine use in children? Australian asthma educator perspectives

The global burden of childhood asthma is significant. Health care systems are faced with increasing financial costs, while children with asthma and their caretakers are faced with poorer physical health, emotional health, and quality of life. Despite the availability of effective treatment, the quality use of asthma medicines in children remains suboptimal. An investigation was conducted to explore issues related to children's asthma medicine usage from the perspective of the health care professional. Although current literature has elicited the views of caretakers and children, the health care professional viewpoint has been relatively unexplored. Semi-structured qualitative interviews were conducted with a convenience sample of 21 Australian asthma educators. Interviews were audiotaped and transcribed, and transcripts were thematically analyzed with the assistance of NVivo 7. Emergent themes associated with health care professionals, parents, medicines, children, and educational resources were found. Major issues included a lack of information provided to parents, poor parental understanding of medicines, the high cost of medicines and devices, child self-image, the need for more child responsibility over asthma management, and the lack of standardization, access to, and funding for educational resources on childhood asthma. There are multitudes of key issues that may affect asthma medicines usage in children. This research will help inform the development of educational tools on the use of medicines in childhood asthma that can be evaluated for their effectiveness in getting key messages to target audiences such as children, caretakers, and teachers.

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

The lived experience of fathers who have children with asthma: a phenomenological study

Asthma is a common chronic illness of childhood and a major cause of school absenteeism and hospitalization. When a child is diagnosed with asthma, parents become responsible for the long-term management of a chronic condition that is characterized by unpredictable and irregular episodes. Much of the research concerning parenting children who have asthma had focused on mothers. Paternal experiences in caring for a child with asthma have received little attention. In this phenomenological study, van Manen's (Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. The Althouse Press: London, ON) method of inquiry was used to explore the lived experience of fathers who have children with asthma. Eight fathers with children aged between 7 and 11 years who had been diagnosed with asthma were interviewed. Five themes were identified: feeling relief in knowing the diagnosis, learning the ropes, being vigilant, living with concern, and being comfortable with asthma management. Understanding the experience of fathers who have children with asthma and gaining insight into their needs and concerns are essential first steps to providing supportive nursing care.

Demands and resources: parents of school-age children with asthma

Asthma is one of the most common chronic diseases in children and is frequently noted as the reason for school absences. The purpose of this pilot study was to determine the differences in demands and resources reported by African American (AA) and European American (EA) parents of school-age children with asthma. A convenience sample of 37 parents participated in the study. Data were collected from 19 AA and 18 EA parents. Family stress theory provided the framework for this study. All subjects completed a demographic questionnaire, the Care of My Child With Asthma Scale, and the Family Inventory of Resources for Management (FIRM). Descriptive statistics were used to analyze the data. The most time-consuming caregiving demand reported by EA parents was providing emotional support for the child. For AA parents, the most time-consuming caregiving demand was managing work or school outside the home and organizing asthma treatments at the same time. AA parents had limited resources in the area of extended family social support. The Mann-Whitney U test found no statistically significant differences between AA and EA parents in relation to demands and resources. Nursing implications are presented.

Hardiness in families of young children with asthma

AIMS

This paper reports a study (a) to assess whether there are cultural and gender differences in parents' general well-being, sense of coherence and perception of family hardiness when they have a young child with asthma; and (b) to examine the effects of parents' sense of coherence and well-being on family hardiness.

BACKGROUND

Research on hardiness, a resilience factor that fosters adaptation over time, has been widely studied from an individual perspective, but less from the viewpoint of the family unit. In particular, no study was found that assessed how members of a couple interact to affect their family's hardiness. Consideration of this dyadic phenomenon may provide unique insight about how family members interact with each other faced with a challenge, such as the chronic illness of a child.

METHODS

A cross-sectional research design was used with a sample of 137 two-parent families [76 from Iceland and 61 from the United States of America (USA)]. Questionnaires measuring sense of coherence, parents' well-being and family hardiness were used, and demographic data were also collected.

RESULTS

The most striking differences in well-being were between mothers and fathers. In addition to a lower average on the total score for the well-being scale, mothers had poorer scores than fathers on the subscales of depression, self-control, vitality, and general health. Family hardiness differed between countries. The regression indicated that the individual's sense of coherence, depression and positive well-being (all actor effects), as well as the partner's anxiety (partner effect) all contributed significantly to family hardiness, as did nationality.

CONCLUSION

Focused interventions for families with young children with asthma should be developed to enable them to feel more confident in using their resources to meet their demands and increase parents' general well-being and family adaptation. Research is needed to develop and test such interventions, particularly with diverse participant samples, encompassing not only a variety of ethnicities, but also a range of children's ages.

Patient-identified barriers to asthma treatment adherence: responses to interviews, focus groups, and questionnaires

This article reviews 32 patient-interview studies that revealed that the most common barriers to adherence revealed by patients included concerns about drug safety and cost and a belief that the patient's asthma was not severe enough to require daily treatment. Important but less commonly cited concerns included worry about dependence or diminished effectiveness with long-term use of the medication. Children and their parents expressed concerns about safety, dependence, peer stigmatization, and parent-child conflict over taking medication. Low-income and minority patients cited similar concerns and barriers that included cost, difficulty of obtaining medication, daily life hassles, and a general distrust of the medical establishment. The information obtained from patients' perspectives indicates the need to reappraise current strategies for the management of asthma, including a more flexible approach to the use of expert guidelines for the treatment of asthma.

Pediatric asthma: a look at adherence from the patient and family perspective

Although extensive research has been done in an effort to understand and promote adherence in pediatric asthma, little progress has been made in reducing the prevalence of nonadherence. Some researchers argue that a paradigm shift is necessary to advance the adherence field. Despite the recent trend for increasing the role of families in determining treatment plans, a patient-centered approach has been lacking in adherence to a daily regimen. It is clear that, although patients and families show evidence of inadvertent nonadherence (eg, forgetfulness), they also engage in volitional or intentional nonadherence, via reasoned and purposeful decisions. Patients conduct "experiments" with their regimen components in an effort to balance the burden of disease with the burden of treatment. These experiments typically involve some degree of nonadherence. Perhaps, if researchers strive to better understand the decision-making process involved in these experiments, health care providers can guide families in making adherence decisions that would lead to attainment of treatment goals, improvement in quality of life, and realization of positive clinical outcomes.