Complementary and Alternative Medicine Behaviors and Beliefs in Urban Adolescents with Asthma

Background/purpose. Up to 80% of adolescents with asthma have used complementary and alternative medicine (CAM) for symptom management. However, little is known about patient characteristics associated with CAM factors other than use. Previous studies recommend provider–patient discussion of CAM use, although few adolescents with asthma disclose their CAM use to their providers. To inform clinical interactions, this study examined prevalence and predictors of CAM use, consideration of use, disclosure of use, and perceived efficacy of use, in urban adolescents with asthma. Methods. Adolescents with asthma (N = 151) recruited from a children's hospital completed questionnaires addressing demographic and clinical variables and 10 CAM modalities. Response frequencies to four questions assessing CAM use, consideration of use, disclosure, and perceived efficacy were calculated for each modality. Multivariable logistic regression analyses examined characteristics associated with responses to each question for the two most commonly used CAM modalities. Results. Participants' mean age was 15.8 (SD = 1.8), 60% were female and 85% were African-American. Seventy-one percent reported using CAM for symptom management in the past month. Relaxation (64%) and prayer (61%) were the most frequently reported modalities and were perceived to be the most efficacious. Adolescents most commonly reported considering using relaxation (85%) and prayer (80%) for future symptom management. Participants were most likely to disclose their use of yoga (59%) and diet (57%), and least likely to disclose prayer (33%) and guided imagery (36%) to providers. In multivariable analyses, older adolescents (OR = 1.27, p < .05) and African-Americans (OR = 2.76, p < .05) were more likely to use relaxation. Adolescents with more frequent asthma symptoms (OR = 0.98, p < .05) were more likely to use prayer. African-Americans were more likely to report using prayer (OR = 3.47, p < .05) and consider using prayer (OR = 7.98, p < .01) in the future for symptom management. Conclusions. Many urban adolescents used and would consider using CAM, specifically relaxation and prayer, for asthma symptom management. African-Americans, older adolescents, and those with more frequent symptoms were more likely to use and/or consider using CAM. Providers caring for urban adolescents with asthma should discuss CAM with patients, particularly those identified as likely to use CAM. Future studies should examine relationships between CAM use and health outcomes.     

Cumulative Risk and Asthma Outcomes in Inner-City African-American Youth

A cumulative risk framework was used to examine the impact of the presence of multiple risk factors on key asthma outcomes (i.e., health-related quality of life [HRQoL], severity) for a sample of 149 inner-city African-American youth with asthma. The presence of a greater number of risk factors was associated with lower HRQoL and greater severity, regardless of age or gender. Cumulative risk methodology, in combination with selection of risk factors based on theoretical and empirical work, is a viable option for researchers and clinicians who are interested in examining the impact of multiple risk factors on disease functioning and status.     

Cumulative Risk and Asthma Outcomes in Inner-City African-American Youth

A cumulative risk framework was used to examine the impact of the presence of multiple risk factors on key asthma outcomes (i.e., health-related quality of life [HRQoL], severity) for a sample of 149 inner-city African-American youth with asthma. The presence of a greater number of risk factors was associated with lower HRQoL and greater severity, regardless of age or gender. Cumulative risk methodology, in combination with selection of risk factors based on theoretical and empirical work, is a viable option for researchers and clinicians who are interested in examining the impact of multiple risk factors on disease functioning and status.     

Unmet Needs of Older People with Asthma: Cross-Sectional Survey

Introduction. Asthma in older people is a major cause of disease burden in Australia and is projected to increase over the next two decades. Current guidelines for asthma care rely predominantly on studies from younger populations. Methods. We undertook a cross-sectional survey of older people with asthma to identify their concerns and their perceived asthma symptom burden. One hundred and ninety-nine people over 55 years of age with asthma were recruited from community pharmacies, in the states of Victoria and NSW, Australia. Results. One-hundred and twenty (62%) participants reported “perfectly” or “very well controlled” asthma over the past month, and 78% claimed adherence to asthma treatment. Despite this, 105 (55%) reported experiencing moderate to severe symptoms and 58 (30%) moderate to extreme restrictions on their lifestyle in the past month. Exacerbations were also common with over one-third of participants seeking emergency asthma care or requiring oral corticosteroids in the past 12 months. In spite of 80% of participants reporting confidence of how to manage their asthma properly, only 10% said they would call an ambulance or visit an Emergency Department if their asthma was “out of control.” Further asthma self-management education was considered desirable by two-thirds. However, those over 65 years preferred less autonomy in decision-making compared to those under 65 years. Conclusion. Older people with asthma experience a high symptom burden. A simplified version of our questionnaire could assist GPs, specialists, and asthma educators to identify the individual needs of older patients and to tailor their delivery of asthma care accordingly.     

Devaluation,Loss, and Rage: A Postscript to Urban African American Youth with Substance Abuse

This article explores and discusses the sociocultural dynamics underpinning urban African American youths' use and misuse of substances and its connection to the invisible wounds of race-related trauma. A racially-sensitive framework is discussed as an intervention approach designed to address the special needs of urban Africa American adolescents maligned by, and suffering from, the complex interplay of substance misuse and rage.     

Behavioral Problems in Children and Adolescents with Difficult-To-Treat Asthma

Background. The aim of this study was to quantify behavioral problems in clinically treated children and adolescents with asthma and to examine the association of these problems and quality of life with difficult-to-treat asthma. Methods. Clinical patients with difficult-to-treat asthma (n = 31) and patients with asthma who were not classified as difficult-to-treat asthma (n = 52) completed the Pediatric Asthma Quality of Life Questionnaire [PAQLQ(S)]. Their parents completed the Child Behavior Checklist (CBCL) to assess behavioral problems. Behavioral problem scores were compared to norms of population reference groups and both behavioral problems and quality of life were compared between children and adolescents with and without difficult-to-treat asthma. Results. Especially internalizing behavioral problems such as being withdrawn/depressed and somatic complaints were more severe in the asthmatic groups compared to the healthy reference groups. The behavioral problems ‘somatic complaints’ and ‘thought problems’ as well as a lower quality of life were more severe in children and adolescents with difficult-to-treat asthma than in asthma patients who did not fulfill the criteria of difficult-to-treat asthma. Conclusions. Behavioral problems and a lower quality of life are suggested to be more pronounced in clinically treated children and adolescents with difficult-to-treat asthma than in asthma patients who are not classified as difficult-to-treat asthma. With respect to practical implications, our data suggest that health-care professionals should – especially in children and adolescents with difficult-to-treat asthma – assess and, if necessary, treat behavioral problems.     

Text Messaging to Measure Asthma Medication Use and Symptoms in Urban African American Emerging Adults: A Feasibility Study

Objective. Urban African American adolescents and young adults face disproportionate risk of asthma morbidity and mortality. This study was the first to assess the feasibility of Ecological Momentary Assessment via text messaging to measure asthma medication use and symptoms in African Americans aged 18–25 years. Methods. This study used automated text messaging with N = 16 participants for 14 consecutive days. Participants sent event-based messages whenever they experienced asthma symptoms or took asthma rescue or controller medications. They also received time-based messages daily that prompted for a response about asthma medications or symptoms. Results. Feasibility was assessed using response rates and participant feedback. Rates of event-based messages were relatively low (M = 0.85 messages sent per participant/day), but participants were very responsive to time-based messages (78.5%). All participants expressed positive feedback about the program, though 40.0% reported confusion with event-based messages and most preferred time-based messages. The assessment found low medication adherence rates and reasons for missing medication consistent with previous research with youth with asthma. Conclusion. Text messaging may be a useful method to measure medication use and symptoms in “real time,” particularly using time-based prompts. Results could be used to provide personalized feedback on adherence as part of a tailored intervention.     

Risk Factors for Asthma Prevalence Among Urban and Nonurban African American Children

Urban residence is a risk factor for asthma. We examined multiple risk factors simultaneously among African American children. We interviewed 2409 African American mothers of newborns who had at least 1 child at home under 18 years of age. Sixteen percent reported at least 1 child with physician-diagnosed asthma. Significantly associated with an asthmatic child were maternal asthma and allergies, maternal cigarette smoking, a humidifying device, and a gas range or oven in the home. Urban residence was related to asthma but became nonsignificant once other factors were controlled for. Asthma associated with urban residence may be explained by identifiable factors.     

Effects of Coping-Skills Training in Low-Income Urban African-American Adolescents with Asthma

Background. Minority teens with asthma are at particular risk for this life-threatening disease due to increased morbidity and mortality rates in addition to the normal challenges of adolescence. Objective. The purpose of this randomized controlled trial (n = 137) was to determine the effects of a coping-skills training program (intervention) compared with standard asthma education (attention control) in African-American teens with asthma. Methods. Adolescents were recruited from five African-American dominant high schools serving low-income areas of Chicago. Data were collected at baseline, 2 months (immediately following the intervention), 6 months, and 12 months. Results. Both groups improved over time, with significant increases in asthma-related quality of life, asthma knowledge, and asthma self-efficacy, accompanied by decreases in symptom days and asthma-related school absences. Conclusions. Findings suggest that coping-skills training as implemented in this study provided no additional benefit beyond that experienced in the control group. However, group-based interventions delivered in the school setting may be beneficial for low-income, minority teens with asthma.     

Factors Associated with Completion of a Behavioral Intervention for Caregivers of Urban Children with Asthma

Background. Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma. Objective. The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters. Methods. Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child’s primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables. Results. Children were African-American (95%), Medicaid insured (91%), and young (aged 3–5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3–5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention. Conclusions. The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.     

Asthma Self-Management is Sub-Optimal in Urban Hispanic and African American/Black Early Adolescents with Uncontrolled Persistent Asthma

Introduction. Youth as young as 11 are given responsibility to manage their asthma. Yet, little is known regarding early adolescents’ asthma self-management behaviors. This study characterizes urban early adolescents’ asthma self-management behaviors and perceived responsibility to manage asthma, exploring demographic differences and examining the relationship between asthma responsibility and disease management. Methods. About 317 Hispanic and African American/Black early adolescents (mean age = 12.71) with persistent, uncontrolled asthma reported prevention and symptom management steps, and responsibility for asthma care. We used Poisson, cumulative logistic, logistic, and linear mixed-effects regression models to assess the relationships among demographic predictors, prevention and management behaviors, and responsibility for asthma care. Results. Fifty percent took 7–9 prevention steps; few saw physicians when asymptomatic or took daily medication. When symptomatic, 92% used medication to treat symptoms and 56% sought medical attention. Controlling for asthma responsibility, fewer older youth reported observing how they feel when asthma is likely to start, observing symptom changes, or asking for help. More boys reported taking medication daily or upon trigger exposure. Controlling for age, gender, and race/ethnicity, those reporting more asthma responsibility were less likely to report taking management steps, seeking preventive care, asking for help, or going to a doctor/hospital for their asthma. Conclusions. Early adolescents’ asthma self-management is suboptimal. With increasing age, they are less observant regarding their asthma and less likely to seek help. Although they perceive themselves to have greater responsibility for managing their asthma, early adolescents do less to care for their asthma, suggesting they are being given responsibility for asthma care prematurely.     

Productive Activities and Perceived Well-Being in an African American Older Adult Urban Sample

Few studies have examined the relationship between productive activities and well-being among urban lower-income African American older adults. The purpose of this study was to examine (1) the pattern and prevalence of types and specific kinds of productive activities and (2) the association among sociodemographic data, individual capacity, kinds and levels of productive activity, and well-being at the individual level. Approximately 12% of 531 respondents participated in employment, whereas 20% participated in volunteer activities. The majority of the respondents (99.4%) joined in leisure activities. More than 75% engaged in religious activities. The respondents also reported that they participated in various kinds of productive activities. Age, physical health status, perceived social support, and perceived neighborhood satisfaction were the most important regression predictors of perceived well-being. Higher levels of involvement in religious activities and leisure activities were related to a greater perceived well-being.     

Effectiveness of Asthma Education with and Without a Self-Management Plan in Hospitalized Children

Background. Formal education in primary care can reduce asthma exacerbations. However, there are few studies in hospitalized children, with none originating in Latin America. Methods. A prospective randomized study was designed to evaluate whether a full education with self-management plan (ESM) was more effective than an education without self-management plan (E) in reducing asthma hospitalization. Children (5 to 15 years of age) who were hospitalized for an asthma attack were divided in two groups. Children in the E group received general instructions based on a booklet. Those in the ESM group received the same booklet plus a self-management guide and a puzzle game that reinforces the lessons learned in the booklet. Patients were interviewed every 3 months, by telephone, for one year. Interviewers recording the number of hospitalizations, exacerbations, and emergency visits for asthma and oral steroid burst uses. Results. From 88 children who met the inclusion criteria, 77 (86%) completed one year of follow-up (41 from E and 36 from ESM group). Overall, after one year, the hospitalization decreased by 66% and the inhaled corticosteroids therapy increased from 36% to 79%. At the end of the study, there was no difference in exacerbations, emergency visits, oral steroid burst uses, or hospitalizations between the two groups. Conclusions. Asthma education with or without a self-management plan during asthma hospitalization were effective in reducing exacerbations, emergency visits, oral steroid burst uses, and future rehospitalizations. This evidence supports the importance of providing a complete asthma education plan in any patient who is admitted for asthma exacerbation.     

Evaluation of Risk Factors and Health Outcomes among Persons with Asthma

Objective: To examine risk factors associated with healthcare utilization in Arizona Medicaid patients with asthma. Methods: Data were obtained from Arizona Medicaid between 1/1/2002 and 12/31/2003. Inclusion criteria consisted of persons with an asthma diagnosis (ICD9-CM 493.XX), 5 to 62 years of age; and were new users of inhaled-corticosteroids (ICS), combination ICS+long-acting beta-agonist, or leukotriene-modifiers. Factors examined included age, geographic location (urban/rural), race/ethnicity (White, non-Hispanic Black, Hispanic, other), medication adherence, pre-period short-acting beta-agonist use (SABA), and co-morbidities. Utilization measures examined included SABA use; exacerbations measured by hospital visits; and asthma-related and total healthcare costs. Analyses for utilization measures were performed using negative binomial, logistic regression, and generalized linear modeling gamma-family, log-link, respectively. Results: A total of 3,013 subjects met inclusion/exclusion criteria and had a mean age (±SD) of 24.7 ±13.7 years. Urban residents were 55% more likely to have an exacerbation than rural residents (odds ratio-OR 0.45, 95%CI: 0.27–0.78). Age (years 18 to 62) was a significant predictor for SABA use (incidence rate ratio-IRR 1.22, 95% CI: 1.06–1.41); and exacerbations (OR 2.07, 95% CI: 1.28–3.38). Mean predicted asthma cost was $530 (95% CI: $461–608) for ages 5 to 17, $702 (95% CI $600–822) for ages 18 to 39), and $583 (95% CI $468–726) for ages 40 to 62. Males were 46% less likely to have an exacerbation than females (OR 0.54, 95% CI: 0.31–0.94). Exacerbations were not different between race/ethnicity categories. Predicted mean asthma-related costs were not different between Whites ($591, 95% CI: $509–686), Blacks ($638, 95% CI: $499–815), or Hispanics ($535, 95% CI: $466–614). Conclusions: Results of these analyses found urban areas had higher rates of asthma-related hospital visits compared to rural counties, but no difference in asthma-costs between urban and rural areas which may suggest rural exacerbations may be more costly or severe. Persons with asthma aged 18 to 62 had higher rates of asthma-related emergency-room visits/hospitalizations than those aged 5 to 18. Persons 18 to 39 years of age had higher costs than person 5 to 17 or 40 to 62. Race/ethnicity in this population was not a significant predictor of outcomes or asthma-related costs.     

An Assessment of Change in Asthma Control among Adolescents and Adults with Persistent Asthma In Mometasone Furoate/Formoterol Fumarate Clinical Trials

Objective. This article provides evidence on the psychometric properties of the Asthma Control Questionnaire (ACQ) in adolescent and adult patients with persistent asthma treated with a combination of inhaled glucocorticoid and long-acting beta2-agonist (LABAs), and explores the factors associated with important improvements in asthma control. Methods. Data from patients in two large (n = 737 and 772) Phase III, randomized, double-blind, parallel-group, multi-center, placebo-controlled studies of mometasone furoate/formoterol fumarate (MF/F) combination formulation compared with monotherapies in subjects with persistent asthma previously treated with either low- or medium-dose inhaled glucocorticoids were used to evaluate the ACQ psychometric properties and predictors of important ACQ improvement, defined as an ACQ score decline from baseline of 0.5 or more at the end of treatment. Results. With 15% and 8% participation from adolescents in the low- and medium-dose studies, the ACQ yielded acceptable reliability (intraclass correlation coefficient ≥ 0.75), and baseline and change scores demonstrated moderate to strong correlations with other baseline measures and change scores in other measures of asthma-related health, including the Asthma Quality of Life Questionnaire (AQLQ12+) domains and total scores. More MF/F treatment group patients (48%) achieved an important ACQ change at 26 weeks compared with MF (32%), F (26%), and placebo (18%) treatment groups (p < .001). Use of rescue medications before randomization was a significant predictor of important ACQ improvement in both studies. Conclusions. These findings support the psychometric properties of the ACQ to measure asthma control among persistent asthma patients and provide confidence in the significant improvements in asthma control demonstrated by the MF/F treatment group.     

Ethnic-Specific Differences in Bronchodilator Responsiveness Among African Americans, Puerto Ricans, and Mexicans with Asthma

Socioeconomic and environmental differences do not fully explain differences in asthma prevalence, morbidity, and mortality among Puerto Ricans, African Americans, and Mexican Americans. Differences in response to albuterol may be a factor. We compared bronchodilator responsiveness between these three populations. All groups demonstrated below expected responsiveness. Puerto Ricans of all ages and African American children with moderate-to-severe asthma demonstrated the lowest responsiveness overall. Among subjects with moderate-to-severe asthma, children were even less likely than adults to show the expected bronchodilator response. We conclude that ethnic-specific differences in bronchodilator drug responsiveness exist between Mexicans, Puerto Ricans, and African Americans with asthma. This may be of importance in asthma management.     

Prevalence of Self-Reported Asthma in Urban and Rural Areas of Turkey

Background and purpose. The risk factors for asthma in rural and urban population of Turkey are not well known. In this study we examined the effects of risk factors on the prevalence of asthma in adults living in rural and urban areas using data from a representative sample. Methods. Parents and grandparents of students from 20 randomly selected primary schools in urban and rural areas of Kirikkale, Turkey, were asked about respiratory diseases using the respiratory questionnaire, which were returned to us by their children. Results. Out of 13,225 parents and grandparents of primary school students 12,270 returned the questionnaires, for an overall response rate of 92.7%. The prevalence of asthma was more common in adults living in rural areas than in urban areas (10.8% vs. 6.2%, p < .0001, respectively). Asthma was more prevalent in women exposed to biomass smoke than those who were not exposed to it in rural areas (14.8% vs. 6.6%, p = .0001, respectively). Frequent childhood respiratory infections were more common in adults living in rural areas than in urban areas (18.2% vs. 10.9%, p < .0001, respectively). Exposure to biomass smoke and frequent childhood respiratory infections were associated with an increased risk of asthma, after adjusting for possible confounding factors in the logistic model for rural subjects. Chronic rhinitis (p = .0001) and frequent childhood respiratory infections (p = .0001) were associated with an increased risk of asthma, after adjusting for possible confounding factors in the logistic model for urban subjects. Conclusions. The prevalence of asthma in adults living in the rural areas of the Kirikkale Region in Central Turkey was significantly higher than that in the urban population. Exposure to biomass smoke and childhood respiratory infections were more common in adults living in rural areas. The higher rate of asthma in adults living in rural areas may be due to a higher frequency of childhood respiratory infections and exposure to biomass smoke.     

The Relationship Between Specific Anxiety Syndromes and Somatic Symptoms in Adolescents with Asthma and Other Chronic Diseases

Background. The impact of a chronic disease on the emotional well-being of children and adolescents is controversial in the literature. This study tested the hypotheses that 1) a specific approach is required to assess emotional deviations in adolescents with chronic diseases and 2) specific anxiety symptoms are predictive of excessive somatic symptoms. Methods. Emotional and somatic symptoms were measured in four groups, selected from a community sample of 897 adolescents: 32 with asthma, 20 with other severe chronic diseases, 30 with median scores (the true comparison group), and 29 with minimal scores on common measures of trait anxiety and depression. Results. The asthma and chronic disease groups scored not significantly higher than the true comparison group on trait anxiety, depression, negative affectivity, five anxiety syndromes, anxiety-related physical, and miscellaneous somatic symptoms. The asthma and chronic disease groups scored only higher than the true comparison group on panic attacks and respiration symptoms. Regression analyses showed that severity of asthma was no significant factor, and the minimal group scored consistently lower than the other groups, except on physical injury fears. There were no group differences in positive affect. Girls scored higher than boys on specific anxiety syndromes (except on obsessive-compulsive disorder) and also on respiration symptoms. Conclusion. Adolescents with severe chronic diseases deviated from a true comparison control group on panic attacks, but not on other negative and positive emotions.     

A Comparison of Self-Rated and Objectively Measured Successful Aging Constructs in an Urban Sample of African American Older Adults

Sixty-seven (N = 67) urban African American older adults were divided into successful and nonsuccessful aging groups based on objective MacArthur (i.e., physical and cognitive functioning) and on self-rated health criteria. Only 30% of the sample met objective MacArthur criteria for successful aging compared to 63% who rated themselves as successful. Self-rated successful aging was best predicted by regular exercise, whereas objective successful aging was best predicted by demographic characteristics and cognition. Reading ability mediated the relationship between both education and cognition to objectively defined success. Finally, objective successful aging was related to quantity and quality of education, whereas self-rated successful aging was related to a wider variety of variables. Defining successful aging on objective factors alone may limit our understanding of successful aging in urban African American older adults.