Factors associated with medication self-administration in children with asthma

Evaluating dry powder inhalers: From in vitro studies to mobile health technologies

Dry powder inhalers (DPIs) are essential in treating patients with pulmonary diseases. Since DPIs were introduced in the 1960s, a remarkable improvement has been made in their technology, dose delivery, efficiency, reproducibility, stability, and performance based on safety and efficacy. While there are many DPIs on the market and several more under development, it is vital to evaluate the performance of DPIs for effective aerosol drug delivery to patients with respiratory disorders. Their performance evaluation includes particle size, metering system, device design, dose preparation, inhalation technique, and patient-device integration. The purpose of this paper is to review current literature evaluating DPIs through in vitro studies, computational fluid models, and in vivo/clinical studies. We will also explain how mobile health applications are used to monitor and evaluate patients' adherence to prescribed medications.

Breathing Together: Children Co-constructing Asthma Self-Management in the United States

Pediatric asthma management in the U.S. is primarily oriented around caregivers. As evident in policy, clinical literature and provider practices, this caregiver-centric approach assumes unidirectional transfer of practices and knowledge within particular relational configurations of physicians, caregivers, and children. Reflecting broader societal values and hierarchies, children are positioned as passive recipients of care, as apprentices for future citizenship, and as the responsibility of parents who will train them in the knowledge and labor of asthma management. These ideas, though sometimes contradictory, contribute to a systemic marginalization of children as participants in their health care, leaving a conceptual gap regarding children's inclusion in chronic illness management: what children's roles in their health care are or should be. We address this conceptual gap by asking, what does pediatric asthma management look like when we center children, rather than caregivers in our lens? We draw data from a study of asthma management in St. Louis, Missouri, and Gainesville, Florida, which included 41 caregivers, 24 children, and 12 health-care providers. By asking children to show us how they manage asthma, we find that children actively co-construct health practices within broader interdependencies of care and the structural constraints of childhoods.

The factors of family management affecting asthma control status in school-age children with asthma in China

OBJECTIVE

To identify the factors of family management affecting asthma control status in school-age children with asthma in China.

METHOD

The cross-sectional descriptive study was conducted among 139 children with asthma and their parents. The age range of the children was 7 to 14 years of age (M_age = 9.85; 76.26% boys). Eight dimensions (Children Identity, View of Condition, Management Mindset, Parental Mutuality, Parenting Philosophy, Management Approach, Family Focus, Future Expectation) of the Family Management Scale for Children with Asthma (FMSCA) were used as factors of family management. The Asthma Control Test (ACT) and the Children Asthma Control Test (C-ACT) were used to measure the asthma control status of children. A parental questionnaire was used to collect information regarding demographic data of familial socioeconomic status, general data about the child, and medical services status (Follow-Up Plan, received manual of asthma education, attended a lecture on asthma) received from medical institutions. A multivariate ordinal logistic regression model was performed.

RESULTS

Factors significantly associated with asthma control were "Follow-Up Plan" (OR, 2.004; 95% CI, 1.009-3.981), "Attended a Lecture on asthma" (OR, 2.586; 95% CI, 1.103-6.066) and two dimensions of the FMSCA, "Children Identity" (OR = 1.133; 95% CI, 1.024-1.254) and "Family Focus" (OR = 1.114; 95% CI, 1.007-1.232).

CONCLUSION

This study shows that asthma control status of school-age children in China is related to the parents' views of their child as having a "normal condition" and the parents' satisfaction with the balance between asthma related management and other aspects of family life.

Association between inhaler technique and confidence among hospitalized children with asthma

OBJECTIVE

Proper use of respiratory inhalers is crucial to asthma self-management and associated with improved outcomes. Previous studies conducted in outpatient and community settings show parents and children are overconfident in children's ability to use inhalers properly, which may lead healthcare providers to not teach or review inhaler technique. This study examined whether children and parents' confidence were associated with proper inhaler technique among children hospitalized with asthma.

METHODS

Children between 5 and 10 years old hospitalized with asthma at an urban academic medical center demonstrated inhaler technique using metered dose inhalers and spacers. Technique was scored based on a validated 12-step scale. Confidence was measured using three items assessing 1. Knowledge to use inhaler, 2. Skills to use inhaler, and 3. Ability to independently use inhaler. These items were five-point scales and analyzed as binary variables. Independent t-tests were used to measure associations between confidence and number of steps performed correctly.

RESULTS

None of the confidence items, when asked to parents or children (n = 70), were associated with the number of steps performed correctly. Further, while the majority of children and parents (59-70%) were confident based on each item, the mean number of steps correctly completed was 6.4 out of 12.

CONCLUSIONS

Children and parents' confidence in children's knowledge, skills, and ability to independently use an inhaler were all poor proxies for proper inhaler technique. Inpatient healthcare professionals should objectively evaluate technique and teach proper inhaler use to all children with asthma to optimize outcomes.

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

INTRODUCTION

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

METHOD

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

RESULTS

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

DISCUSSION

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

A Mixed-methods Study Examining Inhaler Carry and Use among Children at School

Objective: Asthma self-management depends partly on access to inhalers; for children, this includes independent inhaler carry and use at school ("self-carry"). Although laws and policies support self-carry, little is known about practices within schools. This study aimed to identify factors associated with inhaler self-carry among children and examine barriers and facilitators to self-carry.Methods: This mixed-methods observational study included child-parent dyads and nurses from four Chicago schools. Children and parents answered questions about asthma care and morbidity, confidence in self-carry skills, and facilitators and barriers to self-carry. Nurses reported asthma documentation on file and their confidence in children's self-carry skills. Analysis utilized logistic regression. Thematic analysis was performed for open-ended questions.Results: Of 65 children enrolled (mean = 10.66 years), 45 (69.2%) reported having quick-relief medication at school, primarily inhalers, and 35 (53.8%) reported self-carry. Inhaler self-carry was associated with controller medication use and parent confidence in child's self-carry skills. Children and parents identified several facilitators to self-carry: child's asthma knowledge, inhaler characteristics, and need for easy inhaler access. Barriers included child's limited understanding of asthma and inhalers, perception that inhaler is not needed, and limited inhaler access. Children also emphasized social relationships as facilitators and barriers, while parents described children's responsibility as a facilitator and inconsistent policy implementation as a barrier.Conclusions: Efforts to improve inhaler self-carry at school should focus on educating children about asthma and inhaler use, creating supportive environments for self-carry among peers and teachers, and fostering consistent implementation and communication about asthma policy among schools and families.

Comparing inhaled medications reported by adolescents with persistent asthma and their caregivers

Objectives: To compare concordance (agreement) between teens with persistent asthma and their caregivers on the reported number of inhaled asthma medications used (rescue and controller); examine concordance specific to controller medications; and determine whether concordance over controller medications within caregiver/teen dyads is associated with demographics or clinical outcomes.Methods: We used baseline data from the School-Based Asthma Care for Teens (SB-ACT) trial in urban Rochester, NY. Caregivers and teens (12-16 yrs.) with poorly controlled persistent asthma separately reported the teens' inhaled therapy, and could name up to two rescue and two controller medications. We compared the total number of medications and number of controller medications reported by each dyad member with Cohen's Kappa, and assessed whether concordance over the number of controller medications was associated with demographics, symptoms, or healthcare utilization using chi-square and t-tests.Results: Of 210 dyads (79% public health insurance, 61% Black teens), 132 (63%) were disconcordant in reporting the overall number of inhaled medications. Teens or caregivers from 173 dyads (82%) reported any controller medication; however, a majority (61%) were discordant in the reporting of controller medications. Compared with concordant dyads, fewer caregivers from dyads with controller medication discordance reported education past high school (35% vs. 51%, p = 0.04); no other differences in demographics, symptoms, or healthcare utilization were identified based on controller medication concordance.Conclusions: Most dyads identified different numbers of inhaled medications, with substantial disagreement over controller medications. Working to ensure a basic understanding of treatment plans may promote successful self-management in persistent childhood asthma.

Transition Readiness for Talking With Providers in Urban Youth With Asthma: Associations With Medication Management

PURPOSE

Teen readiness assessments may provide a developmental indicator of the transfer of responsibility for health self-management from caregivers to teens. Among urban adolescents with asthma, we aimed to describe teen readiness for talking with providers and identify how readiness relates to responsibility for asthma management, medication beliefs, and clinical outcomes.

METHODS

Teens and caregivers enrolled in the school-based asthma care for teen's trial in Rochester, NY completed in-home surveys. We classified ready teens as those reporting a score of five on both items of the transition readiness assessment questionnaire talking with providers subscale. We performed bivariate analyses to detect differences between ready teens and other teens in teen- and caregiver-reported responsibility, teen medication beliefs, and clinical outcomes (medication adherence over the past 2 weeks, and healthcare use over the past year).

RESULTS

Among this sample of 251 adolescents (mean age: 13.4 years), 35% were classified as "Ready." Ready teens were more likely than other teens to want to use a controller medication independently (7.6 vs. 6.5 out of 10, p < .01) and to have confidence in this ability (8.4 vs. 7.6 out of 10, p = .02). Teens reported poor adherence (missed 52.9% of prescribed controller doses), with no differences in responsibility or clinical outcomes based on level of teen readiness for talking with providers.

CONCLUSIONS

In urban adolescents with poorly controlled asthma, a higher level of teen readiness for talking with providers is associated with higher perceptions of independence in medication taking, but does not appear to relate to clinical outcomes.

Severe Asthma-Perspectives From Adult and Pediatric Pulmonology

Both adults and children with severe asthma represent a small proportion of the asthma population; however, they consume disproportionate resources. For both groups it is important to confirm the diagnosis of severe asthma and ensure that modifiable factors such as adherence have, as far as possible, been addressed. Most children can be controlled on inhaled corticosteroids and long term oral corticosteroid use is rare, in contrast to adults where steroid related morbidity accounts for a large proportion of the costs of severe asthma. Atopic sensitization is very common in children with severe asthma as are other atopic conditions such as allergic rhinitis and hay fever which can impact on asthma control. In adults, the role of allergic driven disease, even in those with co-existent evidence of sensitization, is unclear. There is currently an exciting pipeline of novel biologicals, particularly directed at Type 2 inflammation, which afford the possibility of improved asthma control and reduced treatment side effects for people with asthma. However, not all drugs will work for all patients and accurate phenotyping is essential. In adults the terms T2 high and T2 low asthma have been coined to describe groups of patients based on the presence/absence of eosinophilic inflammation and T-helper 2 (TH₂) cytokines. Bronchoscopic studies in children with severe asthma have demonstrated that these children are predominantly eosinophilic but the cytokine patterns do not fit the T2 high paradigm suggesting other steroid resistant pathways are driving the eosinophilic inflammation. It remains to be seen whether treatments developed for adult severe asthma will be effective in children and which biomarkers will predict response.

I. INTRODUCTION: UNDERSTANDING MEDICINES AND MEDICAL INTERVENTIONS

We live in an increasingly pharmacological and medical world, where children and adults frequently encounter alleged treatments for an enormous range of illnesses. How do we come to understand what heals and why? Here, 15 studies explore how 1,414 children (ages 5-11) and 882 adults construe the efficacies of different kinds of cures. Developmental patterns in folk physics, psychology, and biology lead to predictions about which expectations about cures will remain relatively constant across development and which will change. With respect to stability, we find that even young school children (ages 5-7) distinguish between physical and psychological disorders and the treatments most effective for each. In contrast, young children reason differently about temporal properties associated with cures. They often judge that dramatic departures from prescribed schedules will continue to be effective. Young children are also less likely than older ages to differentiate between the treatment needs of acute versus chronic disorders. Young children see medicines as agent-like entities that migrate only to afflicted regions while having "cure-all" properties, views that help explain their difficulties grasping side effects. They also differ from older children and adults by judging pain and effort as reducing, instead of enhancing, a treatment's power. Finally, across all studies, optimism about treatment efficacy declines with age. Taken together, these studies show major developmental changes in how children envision the ways medicines work in the body. Moreover, these findings link to broader patterns in cognitive development and have implications for how medicines should be explained to children.

Medication identification in pediatric asthma (MED ID): The reliability and validity of a novel screening tool

OBJECTIVES

To evaluate the reliability and validity of medication identification (MED ID), a novel survey assessing caregiver-perceived ability to identify inhaled asthma medications.

METHODS

We analyzed baseline data from the School-Based Asthma Care for Teens trial in Rochester, NY. Caregivers of adolescents with persistent asthma named the inhaled medications used by their child and identified medications on a pictorial chart. Accurate identification was defined as completed matches between listed names and selected images. Caregivers answered the MED ID survey of four scaled questions on perceived ability to identify inhaled medications. We determined internal consistency reliability using Cronbach's alpha; examined concurrent validity by comparing MED ID sum scores with accurate identification using bivariate and multivariate analyses; and assessed the diagnostic utility of MED ID through receiver operating characteristic analysis.

RESULTS

126 caregivers (76% of enrolled) reported >1 inhaled medication; 52% of caregivers accurately identified medications. Two MED ID questions were removed during analysis. The two remaining questions had a score range of 2-10 points; higher scores indicate greater caregiver-perceived ability to identify medications. The Cronbach's alpha was 0.603. Accurate identification of medications was associated with a higher mean MED ID score (8.6 vs 7.6, p = 0.01). Accuracy was most strongly associated with MED ID scores ≥8 points (88% vs 60%, p < 0.001, Phi 0.32); findings were consistent in regression analysis. The greatest area under the curve was seen with MED ID scores ≥8 points (0.638).

CONCLUSIONS

The two-item MED ID survey is a reliable and valid way to assess caregiver's ability to identify inhaled asthma medications.

Asthma Home Management in the Inner-City: What can the Children Teach us?

OBJECTIVE

Knowledge of asthma home management from the perspective of poor, minority children with asthma is limited.

METHOD

Convenience sampling methods were used to recruit families of low-income children who are frequently in the emergency department for uncontrolled asthma. Thirteen youths participated in focus groups designed to elicit reflections on asthma home management. Data were analyzed using grounded theory coding techniques.

RESULTS

Participants (Mean age = 9.2 years) were African American (100%), enrolled in Medicaid (92.3%), averaged 1.4 (standard deviation = 0.7) emergency department visits over the prior 3 months, and resided in homes with at least 1 smoker (61.5%). Two themes reflecting multifaceted challenges to the development proper of self-management emerged in the analysis.

DISCUSSION

Findings reinforce the need to provide a multipronged approach to improve asthma control in this high-risk population including ongoing child and family education and self-management support, environmental control and housing resources, linkages to smoking cessation programs, and psychosocial support.

Inhaler Technique in Children With Asthma: A Systematic Review

BACKGROUND

Pediatric asthma is an important public health problem worldwide. The primary methods of medication delivery are inhalation devices.

OBJECTIVES

This systematic review examined: 1) what is the prevalence of correct inhaler technique among children with asthma, 2) are educational interventions associated with improved rates of correct inhalation technique, and 3) is improved inhaler technique associated with improved asthma outcomes?

DATA SOURCES

We included experimental and observational studies through searches of PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL Complete, and clinicaltrials.gov.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

Studies were eligible for this review if at least 1 outcome measure of the study included and reported results of child/adolescent inhaler technique.

STUDY APPRAISAL AND SYNTHESIS METHODS

The following information was extracted from each included study: study design (experimental vs observational), and outcomes data. The Downs and Black checklist was used to appraise study quality.

RESULTS

Twenty-eight studies were eligible for inclusion. We found that inhaler technique is generally very poor among children, but is better when children use their metered-dose inhalers (MDIs) with spacers. Technique in using turbuhalers and diskus inhalers is better than in MDI, but still poor. Counseling children on correct inhaler technique was associated with improved technique among children in multiple studies.

LIMITATIONS

We examined articles published in English.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Inhaler technique in children is generally poor. Physicians and other members of the health care team should instruct children and their caregivers on the proper use of their inhalation devices at every opportunity and correct mistakes when made to ensure effective medication delivery.

REGISTRY

This systematic review was registered under the Centre for Reviews and Dissemination, PROSPERO CRD42015025070 (http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015025070).

Effects of family treatment on parenting beliefs among caregivers of youth with poorly controlled asthma

OBJECTIVE

Caregiver involvement is critical in ensuring optimal adolescent asthma management. The study investigated whether multisystemic therapy (MST), an intensive home-based family therapy, was superior to family support for changing beliefs regarding asthma-related positive parenting among caregivers of African-American youth with poorly controlled asthma. The relationship between parenting beliefs and asthma management at the conclusion of the intervention was also assessed.

METHODS

A randomized controlled trial was conducted with 167 adolescents with moderate-to-severe, persistent, poorly controlled asthma and their primary caregivers. Families were randomly assigned to MST or family support (FS), a home-based family support condition. Data were collected at baseline and 7-month posttest. Changes in caregiver ratings of importance and confidence for engaging in asthma-related positive parenting were assessed through questionnaire. Illness management was assessed by the Family Asthma Management System Scale.

RESULTS

Participation in MST was associated with more change in caregiver beliefs as compared with FS for both importance (t = 2.39, p = .02) and confidence (t = 2.04, p = .04). Caregiver beliefs were also significantly related to youth controller medication adherence at the conclusion of treatment (importance: r = .21, p = .01; confidence: r = .23, p = .004).

CONCLUSION

Results support the effectiveness of MST for increasing parental beliefs in the value of asthma-related positive parenting behaviors and parental self-efficacy for these behaviors among families of minority adolescents with poorly controlled asthma.

Association between health literacy and child and adolescent obesity

OBJECTIVE

We tested the association between child and parental health literacy (HL) and odds of child and adolescent obesity.

METHODS

We conducted an anonymous cross-sectional survey of a convenience sample of English-speaking child-parent dyads. Newest Vital Sign (NVS) measured HL. We used multivariable logistic regression to test adjusted association between child and parental NVS and obesity. Analyses were stratified for school-aged children (aged 7-11) vs. adolescents (aged 12-19).

RESULTS

We surveyed 239 child-parent dyads. Median child age was 11 [inter-quartile range 9-13]; 123 (51%) were male; 84% Medicaid recipients; 27% obese. For children, the odds of obesity [adjusted odds ratio (95% confidence interval)] decreased with higher parent NVS [0.75 (0.56,1.00)] and increased with parent obesity [2.53 (1.08,5.94)]. For adolescents, odds of obesity were higher for adolescents with the lowest category of NVS [5.00 (1.26, 19.8)] and older parental age [1.07 (1.01,1.14)] and lower for Medicaid recipients [0.21 (0.06,0.78)] and higher parental education [0.38 (0.22,0.63)].

CONCLUSION

Obesity in school-aged children is associated with parental factors (obesity, parental HL); obesity in adolescents is strongly associated with the adolescent's HL.

PRACTICE IMPLICATIONS

Strategies to prevent and treat obesity should consider limited HL of parents for child obesity and of adolescents for adolescent obesity.

Every parent tells a story: why non-adherence may persist in children receiving guideline-based comprehensive asthma care

OBJECTIVE

Effective self-management and adherence to inhaled corticosteroids are issues of particular interest in comprehensive asthma care. In spite of this care, however, a number of parents and children remain non-adherent. The reasons for this non-adherence have up till now been unknown, because previous adherence studies have based their findings either on populations with poor adherence or on unreliable self-reported adherence. This study was designed to explore factors that contribute to persistent non-adherence to inhaled corticosteroids in children ranging between 2 and 12 years of age receiving comprehensive asthma care, with adherence assessed objectively.

METHODS

This qualitative study was based on in-depth interviews which took place in the homes of parents whose children had completed a one-year follow-up of electronically measured adherence to inhaled corticosteroids. Rich and comprehensive descriptions of parents' own accounts of self-management behavior were obtained using active listening techniques. Each interview was recorded and transcribed verbatim followed by data analysis using standard methodology for qualitative studies.

RESULTS

Twenty children's parents (mean age 5.9 years) were interviewed. Distinctive patterns of modifiable barriers to adherence emerged, including a novel finding of parents misjudging their child's ability to manage the daily use of medication by him/herself. Persistent non-adherence appeared to be caused by a number of maintaining factors. Most noticeable factors were unawareness of non-adherence by both parents and health care providers, a lack of parental drive to achieve high adherence and ineffective parental problem-solving behaviour.

CONCLUSIONS

This study has identified modifiable barriers to adherence in families participating in a comprehensive asthma care programme. Future studies are needed to verify our novel findings and to investigate whether interventions around these barriers are needed to increase the effectiveness of asthma care programs.

Automedicação em menores de cinco anos em municípios do Pará e Piauí: prevalência e fatores associados

OBJETIVOS: medir a prevalência e identificar fatores associados à automedicação em crianças menores de cinco anos nos municípios de Caracol no Estado do Piauí, e Garrafão do Norte no Pará. MÉTODOS: utilizando-se de delineamento transversal, amostragem sistemática e utilização de questionário padrão por meio de visita domiciliar, foram investigadas diversas características das mães, das famílias e das crianças. Utilizou-se teste do qui-quadrado para comparar proporções e regressão de Poisson com ajuste robusto da variância na análise multivariável. RESULTADOS: dentre as 590 crianças estudadas em Caracol e 1081 em Garrafão, 30% e 25% haviam sido automedicadas nos últimos 15 dias, respectivamente. Após análise ajustada para diversas variáveis confundidoras, o fato de não conseguir atendimento para o filho doente nos últimos 15 dias nos dois municípios, assim como de residir há mais de 1 km dos serviços de saúde em Caracol e de a mãe exercer trabalho remunerado nos últimos 12 meses em Garrafão mostraram-se significativamente associadas à automedicação entre menores de cinco anos. CONCLUSÕES: a prevalência de automedicação por parte das mães para menores de cinco anos nos municípios estudados, apesar de inferior à observada em outras localidades brasileiras, decorreu, sobretudo, da dificuldade de realização de consulta médica.

Relationship between patient, caregiver, and asthma characteristics, responsibility for management, and indicators of asthma control within an urban clinic

Successful asthma management in children requires an appropriate division of responsibility for management tasks between patient and their family. Non-adherence may result without appropriate assignment or acceptance of responsibility for these tasks. This study explored the relationship between selected child, caregiver, family, and asthma characteristics and responsibility for self-management activities. Child and caregiver perceived responsibility for selected tasks were determined and described via means and mean summary scores. Child, caregiver, family, and asthma characteristics were determined via interview and chart review and described by means or proportions. Pearson's correlation coefficient (r) examined any relationship between these characteristics and perceived levels of responsibility. Multiple regression examined whether the affect of child, caregiver, family, and asthma characteristics influenced perceived levels of responsibility for asthma management. One-hundred and four child and caregiver pairs were enrolled. Mean caregiver scores for all tasks suggest responsibility for each most of the time. The mean child scores for all tasks suggest an unwillingness to assume responsibility most or all of the time. Regression analysis indicated that patient age (r(2) = 0.344), number of hospital admissions (r(2) = 0.052), and PEF (r(2) = 0.106) had the best predictive strength for the patient summary score. Only patient age (r = 0.486) was a significant predictor for the caregiver summary score. We conclude that children and caregivers perceive differently responsibility for asthma management tasks and patient age had the best predictive strength for both patient and caregiver responsibility.

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.

Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis. Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil. The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.

Improving asthma communication in high-risk children

Few child asthma studies address the specific content and techniques needed to enhance child communication during asthma preventive care visits. This study examined the content of child and parent communications regarding their asthma management during a medical encounter with their primary care provider (PCP). The majority of parents and children required prompting to communicate symptom information to the PCP during the clinic visit. Some high-risk families may require an asthma advocate to ensure that the clinician receives an accurate report of child's asthma severity and asthma control to ensure prescribing of optimal asthma therapy.

Internet telehealth for pediatric asthma case management: integrating computerized and case manager features for tailoring a Web-based asthma education program

This article reports on the development of a personalized, Web-based asthma-education program for parents whose 4- to 12-year-old children have moderate to severe asthma. Personalization includes computer-based tailored messages and a human coach to build asthma self-management skills. Computerized features include the Asthma Manager, My Calendar/Reminder, My Goals, and a tailored home page. These are integrated with monthly asthma-education phone calls from an asthma-nurse case manager. The authors discuss the development process and issues and describe the current randomized evaluation study to test whether the year-long integrated intervention can improve adherence to a daily asthma controller medication, asthma control, and parent quality of life to reduce asthma-related healthcare utilization. Implications for health education for chronic disease management are raised.

An evaluation of children's metered-dose inhaler technique for asthma medications

Regardless of the medication delivery system, health care providers need to teach accurate medication administration techniques to their patients, educate them about the particular nuances of the prescribed delivery system (eg, proper storage), and reinforce these issues at each health encounter. A single instruction session is not sufficient to maintain appropriate inhaler techniques for patients who require continued use. Providing written steps for the administration technique is helpful so that the patient can refer to them later when using the medication. The National Heart, Lung, and Blood Institute's "Practical Guide for the Diagnosis and Management of Asthma" recommends that practitioners follow these steps for effective inhaler technique training when first prescribing an inhaler: 1. Teach patients the steps and give written instruction handouts. 2. Demonstrate how to use the inhaler step-by-step. 3. Ask patients to demonstrate how to use the inhaler. Let the patient refer to the handout on the first training. Then use the handout asa checklist to assess the patient's future technique. 4. Provide feedback to patients about what they did right and what they need to improve. Have patients demonstrate their technique again, if necessary. The last two steps should be performed (ie, demonstration and providing feedback on what patients did right and what they need to improve) at every subsequent visit. If the patient makes multiple errors, it is advisable to focus on improving one or two key steps at a time. With improvements in drug delivery come challenges, necessitating that practitioners stay current with new medication administration techniques. Teaching and reinforcing accurate technique at each health care encounter are critical to help ensure medication efficacy for patients with asthma. Since one fifth of children in the study performed incorrect medication technique even after education, checklists of steps for the correct use of inhalation devices, such as those provided in this article, should be given to patients for home use and for use by clinicians to evaluate patient technique at each health encounter.

Evaluating the needs of children with asthma in home care: the vital role of nurses as caregivers and educators

To date, few evaluations have examined issues specific to children's asthma management in their homes. This study examined the characteristics, risk factors, and needs of children with asthma, and the impact of home health nurses on improving parents'/family caregivers' knowledge about asthma triggers and management. The medical records of children, </=19 years, residing in New York City, who were admitted to home care with asthma in 1999 (n = 1,007) were reviewed retrospectively to collect a wide range of data. The majority of children with asthma in home care were </=5 years, male, racial/ethnic minorities, and hospital referred. Approximately one in four children with asthma suffered from additional comorbidities. Home environmental triggers included dust/dust mites, animal dander, mold, perfumes/detergents, and cigarette smoke. Notable psychosocial triggers were family tensions, physical activity, anxiety/stress, and friends/peer pressure. Most parents/family caregivers had inadequate knowledge about recognition of asthma attacks and its triggers and management. Discharge assessments suggested that home health nurses can help improve caregivers' knowledge about asthma management. Children with asthma in home care have diverse needs, receive few nurse home visits, and have parents/family caregivers in need of more intensive education on asthma symptom recognition and management.

Does route of administration affect the outcome of TNF antagonist therapy?

The tumor necrosis factor (TNF) antagonists are parenterally administered biologic response modifiers indicated for the management of rheumatoid arthritis. Although infliximab, etanercept, and adalimumab are all members of this class, they differ in route of administration and dosing regimen. In the USA and in Europe, infliximab, in combination with oral methotrexate, is administered intravenously, initially at a dose of 3 mg/kg at weeks 0, 2, and 6, then every 8 weeks thereafter. The US Food and Drug Administration (FDA) has further approved that the dosage can be increased to 10 mg/kg and the doses can be given as often as every 4 weeks to optimize patient outcome (information based on the US package insert dated June 2002). Etanercept and adalimumab are given subcutaneously and can be self-injected. The FDA-approved dose of etanercept is 25 mg twice weekly, and of adalimumab is 40 mg every 2 weeks with methotrexate, or 40 mg alone. Medication adherence, possibly the most important factor in maintaining the benefits of anti-TNF therapy, is influenced by the interaction between the patient and his or her healthcare team, the patient's attitude toward the disease and medication regimen, and the choice of therapy.

Understanding pediatric inner-city asthma: an explanatory model approach

Explanatory models (EMs) for asthma among inner-city school-age children and their families were examined as a means of better understanding health behaviors. Children and parents were interviewed about their concepts of asthma etiology, asthma medications, and alternative therapies. Drawings were elicited from children to understand their beliefs about asthma. Nineteen children with 17 mothers from a variety of cultural backgrounds were interviewed. Among children, contagion was the primary EM for asthma etiology (53%). Twenty-five percent of children reported fear of dying from asthma, while fear of their child dying from asthma was reported by 76% of mothers. Mothers reported a variety of EMs, some culturally specific, but the majority reported biomedical concepts of etiology, pathophysiology, and triggers. Although 76% of mothers knew the names of more than one of their children's medications, 47% thought their child's medications all had similar functions. Thirty-five percent of families used herbal treatments and 35% incorporated religion into asthma treatment. Seventy-one percent of families had discontinued medications and 23% reported currently not giving anti-inflammatory medication. Reasons for discontinuing daily medications included fears of unknown side effects (53%), addiction (18%), tachyphylaxis (18%), and feeling that their child was being given too much medicine (23%). The traditional focus of asthma education is not sufficient to ensure adherence. Asthma education for children should address their views of etiology and fears about dying from asthma. Conversations with parents about their EMs and beliefs about medications and alternative therapies could assist in understanding and responding to parental concerns and choices about medications and help achieve better adherence.

Children's self-reports of characteristics of their asthma episodes

Our purpose was to examine school-age children's self-reports of characteristics of their asthma episodes including the precipitating events, symptoms experienced during the episodes, and interventions used to resolve the episodes. Children's self-reports of their asthma episodes were assessed over a 6-week period for 42 children with persistent asthma who participated in a randomized, controlled clinical trial to evaluate the efficacy of an asthma self-management program on adherence to recommended daily peak expiratory flow rate monitoring. Children were instructed to answer the following questions on the Asthma Report Form each time they experienced an asthma episode: 1) What were you doing; 2) How did you feel; and 3) What did you do to help your breathing? Of the children, 71% experienced at least one asthma episode during the 6 weeks. There were a total of 206 episodes. Physical activity (51%) was the most cited trigger, cough alone or combined with other symptoms (84%) was the predominant symptom, and rescue asthma medication (59%) was identified most often as the intervention used by the children to resolve the asthma episode. Children's self-reports provided valuable information about their asthma episodes. The finding that most of the children experienced at least one asthma episode during the 6-week period underscores the importance of family education on how to handle asthma episodes effectively at home. Because physical activity was cited most often as a trigger for asthma episodes, families should receive education on preventive steps for averting an asthma episode prior to the child engaging in physical activity.

Hospital readmissions for childhood asthma: a 10-year metropolitan study

Studies of asthma admissions in the St. Louis metropolitan area have disclosed substantial numbers of children with readmissions. To determine the magnitude of readmissions and attributes of children with readmissions, a retrospective analysis of 8,761 children with 14,905 asthma hospitalizations for January 1, 1990 through December 31, 1999 at the two university affiliated children's hospitals in St. Louis was undertaken. Patient attributes of age, sex, race/ethnicity, residence, payor status, length of stay, and month of admission were compared between patients admitted once during that period and patients admitted multiple times. Main outcome measures were the total number of admissions and time to readmission during the study interval. A Lin, Wei, Yang, and Ying model of time to readmission showed that African-American children with Medicaid or no insurance are at higher risk of readmission (risk ratio 1.28) than are African-American patients with commercial insurance or white/other race/ethnicity patients regardless of insurance. Probability of readmission increased from 30% after a first admission, 46% after a second, and 59% after a third. Prior admission was a more specific indicator of readmission with greater positive predictive value than ethnicity or insurance status or their combination.

Adherence to asthma therapy in the preschool child

Preschool children's adherence to asthma therapy is often sub-optimal and can result in decreased quality of life for children and parents, as well as an increased risk for dangerous asthma exacerbations. Asthma management for the preschool child presents some unique challenges to adherence to therapy, including the child's limited ability to communicate, multiple caregivers responsible for medications, and parental concerns about medications. Parent beliefs, characteristics of the regimen, and family functioning have been associated with adherence levels. Understanding and improving adherence to asthma therapy for the preschool child will necessarily require addressing these age-specific concerns.

Enhancing medication adherence among inner-city children with asthma: results from pilot studies

Despite the availability of effective treatments that aid in controlling asthma symptoms, inner-city children with asthma have high rates of morbidity and are frequent users of emergency department services. The goal of these studies was to pilot test an intervention that used social learning strategies (e.g., goal-setting, monitoring, feedback, reinforcement, and enhanced self-efficacy) and targeted known barriers to individualize a family-based asthma action plan. Participants were 15 children with asthma, aged 7-12 years, who had been prescribed at least one daily inhaled steroid. The children and their mothers lived in inner-city Baltimore and all were African-American. Participants received up to five visits in their home by a nurse. Electronic monitors were installed on the children's MDI to provide immediate feedback on medication adherence to the families and validate medication use. At baseline, only 28.6% of the children were using their medications as prescribed. Within four weeks, the number of children who were using their medications appropriately doubled from 28.6% at baseline to 54.1% (90% increase; p = 0.004), while underutilization decreased from 51.2% to 25.4% (100% decrease; p = 0.02). The number of children with no medication use at all dropped from 28.3% at baseline to 15.1% by week 5 (87% decrease; p = 0.009). Thus, within four weeks, more than half the children were using their inhaled steroids appropriately. In addition, the rate of underutilization decreased and that of nonutilization was cut in half. Our initial data suggest that an individualized, home-based intervention can significantly enhance adherence to the daily use of inhaled steroids in inner-city children with asthma. Nevertheless, adherence to daily inhaled steroid therapy remains a significant problem in this group.

Asthma self-management: the perspective of children

This qualitative study explored the knowledge, perceptions, and autonomy of 7- and 12-year-old children relative to the management of their asthma. A total of 32 children with moderate to severe asthma were interviewed using an open-ended drawing interview and a semi-structured interview. The triangulation of results from these two methods revealed developmental differences. Younger children identified medicines by shape, color, or lay terms, relied on adults to manage their asthma, and did not recognize warning symptoms of an attack. Older children mastered biomedical terminology and used medicines independently, although they sometimes asked for the assistance of an adult. All children perceived benefits and non-monetary costs of asthma medicines. However, they lacked understanding of the categories and role of asthma medicines. This study suggests that long-term control and quick-relief metered dose inhalers should be identifiable by consistent color-coding, and that professionals should tailor asthma education and information to children's stages of cognitive development.

Children with asthma and nebulizer use: parental asthma self-care practices and beliefs

We examined demographic characteristics, patterns of medication use, asthma morbidity, and asthma self-management practices and beliefs among inner-city children currently using a nebulizer. We also describe the relationship between asthma self-management practices and beliefs and anti-inflammatory (AI) therapy. We observed a high rate of morbidity, including frequent emergency room visits, hospitalizations, symptom days and nights, and school absences in this group of school-aged children with asthma. More than three-quarters (81%) reported asthma symptoms consistent with mild persistent or greater severity of asthma, and therefore these subjects should be taking AI medications. Another 16% (36 of 231) of these children reported symptoms consistent with mild intermittent asthma. Only 1 out of 7 children in this study reported taking AI medications. We found that parents of children taking daily AI medications were more likely to agree with the belief that children should use asthma medications daily even when the child is not reporting any symptoms.