Barriers to Reducing ETS in the Homes of Inner-City Children with Asthma

This study assessed knowledge regarding the harm of environmental tobacco smoke (ETS) exposure and barriers to reducing ETS from the point-of-view of urban parents of asthmatic children. We conducted in-depth interviews with 15 mothers of children with asthma. All parents had good knowledge regarding the harmful effects of ETS. While all children of smoking parents were exposed to ETS, parents described using various strategies to keep ETS away from children. Many parents experienced significant stress in their lives and used smoking to relieve their stress. Barriers to a smoke-free home included stress, addiction, and the use of ineffective strategies to reduce ETS exposure.     

Barriers to Reducing ETS in the Homes of Inner-City Children with Asthma

This study assessed knowledge regarding the harm of environmental tobacco smoke (ETS) exposure and barriers to reducing ETS from the point-of-view of urban parents of asthmatic children. We conducted in-depth interviews with 15 mothers of children with asthma. All parents had good knowledge regarding the harmful effects of ETS. While all children of smoking parents were exposed to ETS, parents described using various strategies to keep ETS away from children. Many parents experienced significant stress in their lives and used smoking to relieve their stress. Barriers to a smoke-free home included stress, addiction, and the use of ineffective strategies to reduce ETS exposure.     

Pediatric Asthma: Caregiver Health Literacy and the Clinician's Perception

Health literacy was assessed in pediatric asthma caregivers attending a university-based clinic. The medical provider's perception of caregiver health literacy was also examined. Eighty-six percent of the caregivers had adequate health literacy, 4% and 10% had marginal and inadequate health literacy, respectively. Health literacy was significantly higher for caregivers who were younger (p = 0.039) and had a higher level of education (p = 0.037). An agreement analysis revealed moderate agreement between provider perception of caregiver's health literacy and measured health literacy (Kappa = 0.51). The results suggest that medical providers may not accurately assess caregivers' actual health literacy level.     

Pediatric Asthma: Caregiver Health Literacy and the Clinician's Perception

Health literacy was assessed in pediatric asthma caregivers attending a university-based clinic. The medical provider's perception of caregiver health literacy was also examined. Eighty-six percent of the caregivers had adequate health literacy, 4% and 10% had marginal and inadequate health literacy, respectively. Health literacy was significantly higher for caregivers who were younger (p = 0.039) and had a higher level of education (p = 0.037). An agreement analysis revealed moderate agreement between provider perception of caregiver's health literacy and measured health literacy (Kappa = 0.51). The results suggest that medical providers may not accurately assess caregivers' actual health literacy level.     

The Association Between Symptomatic Asthma and Neurobehavioral Comorbidities Among Children

Background. Asthma affects millions of children in the United States. The extent to which asthma and other medical conditions coexist, however, is largely unknown. Objective. This study aimed to determine associations between symptomatic asthma and neurobehavioral comorbidities among children in rural United States. Methods. This cross-sectional study used data from 406 parents/caregivers of children aged 16 or younger, who completed survey questionnaires assessing their child's health status. Symptomatic asthma was defined as parents’/caregivers’ report of physician diagnosed asthma and presence of night-time asthma symptoms in their children. The dependent variables were parents’/caregivers’ reported comorbidities in children. Results. Symptomatic asthma was present in 9% of the sample. Approximately 26% parents/caregivers reported their child had one or more mental health problems and 13% reported one or more neurological problems. In multivariable logistic regression analyses, a statistically nonsignificant 50% elevated odds of one or more mental health problems were observed for children with symptomatic asthma (adjusted odds ratio [OR] = 1.5, 95% confidence interval [CI] = 0.6–3.5). Of the individual comorbidities included in the mental health construct, more than 2-fold elevated odds of anxiety problems (adjusted OR = 2.6, 95% CI = 0.8–8.6) and attentional problems (adjusted OR = 2.4, 95% CI = 1.0–5.8) were observed for symptomatic asthma. The odds of reporting one or more neurological problems were 4-fold elevated (adjusted OR = 4.0, 95% CI = 1.6–10.0) for symptomatic asthma. Of the individual comorbidities included in the neurological construct a significantly elevated odds of hearing impairment or deafness was observed among children with symptomatic asthma (adjusted OR = 8.2, 95% CI = 1.5–45.3) as compared to the no asthma/no symptoms reference group. Conclusion. These data suggest significant associations between symptomatic asthma and neurological comorbidities.     

Agreement Between Teenager and Caregiver Responses to Questions About Teenager's Asthma

It is unknown if teenagers and caregivers give similar responses when interviewed about the teen's asthma. We analyzed data for 63 urban African-American teen-caregiver pairs. Caregivers underestimated teen smoking by 30%, gave lower estimates for teen exposure to passive smoke, and disagreed with teens on controller medication usage. Teen-caregiver responses were not significantly different for estimates of symptom-days, activity limitations, or nights awakened; nor were they significantly different for report of emergency department visits or hospitalizations. Agreement was weak for perceived asthma control and severity. Teen-caregiver agreement on asthma depends on the type of information being sought.     

Agreement Between Teenager and Caregiver Responses to Questions About Teenager's Asthma

It is unknown if teenagers and caregivers give similar responses when interviewed about the teen's asthma. We analyzed data for 63 urban African-American teen-caregiver pairs. Caregivers underestimated teen smoking by 30%, gave lower estimates for teen exposure to passive smoke, and disagreed with teens on controller medication usage. Teen-caregiver responses were not significantly different for estimates of symptom-days, activity limitations, or nights awakened; nor were they significantly different for report of emergency department visits or hospitalizations. Agreement was weak for perceived asthma control and severity. Teen-caregiver agreement on asthma depends on the type of information being sought.     

The Role of Caregivers' Depressive Symptoms and Asthma Beliefs on Asthma Outcomes Among Low-income Puerto Rican Children

Objective. To examine the relationship between depressive symptoms and asthma beliefs (self-efficacy and empowerment), child asthma outcomes, and caregiver's quality of life among Puerto Rican caregivers of children with asthma. Methods. The caregivers of 221 children with persistent bronchial asthma were stratified into those with no/low or high levels of depressive symptoms. Differences between the groups in caregiver self-efficacy, family empowerment, child asthma outcomes, and quality of life were examined. Results. Caregivers with more depressive symptoms reported lower self-efficacy, less empowerment, less symptom-free days and nights for their children, and a lower quality of life compared to caregivers with no or fewer depressive symptoms. Conclusions. Depressive symptoms among Puerto Rican caregivers were associated with asthma beliefs, children's asthma symptoms, and caregiver quality of life. Our findings reinforce the importance of physician screening skills in recognizing caregiver depression in parents of asthma patients.     

Barriers and Facilitators to Healthy Physical Activity in Asthma Patients

Preliminary evidence indicates that asthma patients limit exercise and healthy lifestyle activities to avoid respiratory symptoms. This self-imposed decrease in activity, even among those with mild disease, may predispose to long-term general health risks. The objectives of this qualitative study were to determine patients' views about exercise and lifestyle activities and to determine if these views varied depending on asthma characteristics. During in-person interviews, 60 patients were asked open-ended questions about asthma and perceived barriers and facilitators to exercise and lifestyle activities, particularly walking. Responses were coded and corroborated by independent investigators and then compared according to asthma severity, knowledge, self-efficacy, and attitudes. Although most patients acknowledged the importance of exercise, many either limited or did not participate in exercise because of asthma and other conditions. Patients cited both internal and external barriers to exercise, such as lack of motivation, time constraints, and extreme weather affecting asthma. Patients identified multiple facilitators, such as social support and the desire to be healthy. Lifestyle activities were preferred over formal exercise regimens. Patients with more severe disease were more likely to believe that exercise was not good for asthma. Patients with less knowledge, less self-efficacy, and worse attitudes toward asthma also were more likely to have negative perspectives about exercise. In conclusion, for many patients, asthma is a deterrent to physical activity and predisposes to inactivity. Developing interventions to foster prudent lifestyle activities and exercise among asthma patients should be a priority to decrease long-term health risks.     

Barriers and Facilitators to Healthy Physical Activity in Asthma Patients

Preliminary evidence indicates that asthma patients limit exercise and healthy lifestyle activities to avoid respiratory symptoms. This self-imposed decrease in activity, even among those with mild disease, may predispose to long-term general health risks. The objectives of this qualitative study were to determine patients' views about exercise and lifestyle activities and to determine if these views varied depending on asthma characteristics. During in-person interviews, 60 patients were asked open-ended questions about asthma and perceived barriers and facilitators to exercise and lifestyle activities, particularly walking. Responses were coded and corroborated by independent investigators and then compared according to asthma severity, knowledge, self-efficacy, and attitudes. Although most patients acknowledged the importance of exercise, many either limited or did not participate in exercise because of asthma and other conditions. Patients cited both internal and external barriers to exercise, such as lack of motivation, time constraints, and extreme weather affecting asthma. Patients identified multiple facilitators, such as social support and the desire to be healthy. Lifestyle activities were preferred over formal exercise regimens. Patients with more severe disease were more likely to believe that exercise was not good for asthma. Patients with less knowledge, less self-efficacy, and worse attitudes toward asthma also were more likely to have negative perspectives about exercise. In conclusion, for many patients, asthma is a deterrent to physical activity and predisposes to inactivity. Developing interventions to foster prudent lifestyle activities and exercise among asthma patients should be a priority to decrease long-term health risks.     

Child and Caregiver Involvement and Shared Decision-Making during Asthma Pediatric Visits

Objective. The purpose of this study was to examine () the extent to which caregivers and children asked asthma management questions during pediatric asthma visits; () the extent to which providers engaged in shared decision-making with these caregivers and children; and () the factors associated with question asking and shared decision-making. Methods. Children aged 8–16 years with mild persistent asthma, moderate persistent asthma, or severe persistent asthma and their caregivers were recruited at five pediatric practices in non-urban areas of North Carolina. All of the medical visits were audio tape recorded. Generalized estimating equations were used to analyze the data. Results. Only 13% of children and 33% of caregivers asked one or more questions about asthma management. Caregivers were more likely to ask questions about their child’s medications. Providers obtained child input into their asthma management plan during only 6% of encounters and caregiver input into their child’s asthma management plan during 10% of visits. Conclusion. Given the importance of involving patients during healthcare visits, providers need to consider asking for and including child and caregiver inputs into asthma management plans so that shared decision-making can occur more frequently.     

Barriers to Patient-Clinician Collaboration in Asthma Management: The Patient Experience

Objective. To describe what adult patients with asthma report about their experiences with their own self-management behavior and working with their clinicians to control asthma. Methods. The study sample consisted of 104 patients with persistent asthma participating in a clinical trial on asthma monitoring. All subjects were seen by primary care clinicians of a large, academic medical center. This qualitative post hoc analysis examined the views of adults with asthma about their asthma-related health care. Patients attended monthly visits as part of their study participation, during which data were derived from semistructured interviews. All patients included in this analysis participated in the study for 1 year. At the end of study participation, patients were asked to complete an evaluation of their clinician's communication behavior. All study clinicians were also asked to complete a self-evaluation of their own communication behavior. Results. Five major themes of barriers to successful self-management were identified, including personal constraints, social constraints, communication failures, medication issues, and health care system barriers to collaboration with their clinicians. Patients most frequently reported lack of communication surrounding issues relating to day-to-day management of asthma (31%) and home management of asthma (24%). Clinicians generally rated themselves well for consistency in showing nonverbal attentiveness (89%) and maintaining interactive conversations (93%). However, only 30% of clinicians reported consistency in helping patients make decisions about asthma management and only 33% of clinicians reported consistency in tailoring medication schedules to the patient's routines. Conclusion. These findings emphasize the difficulties of establishing and maintaining a therapeutic partnership between patients and clinicians. The results underscore the need for system-wide interventions that promote the success of a therapeutic patient-clinician relationship in order to achieve long-term success in chronic disease management.     

Providence School Asthma Partnership: School-based Asthma Program for Inner-City Families

Over 3 years, 972 families participated in an after-school asthma program at their child's school. Parents and children attended concurrent 2¹/₂ -hour workshops. Parents were 74% Latino; 45% non-English speaking, with 77% of children on Medicaid. Asthma symptoms were significantly reduced, from multiple times per week to less than once per week on average. Oral steroid use decreased to one third of baseline use. Hospital days decreased from 11% to 2%; emergency visits decreased 35% to 4%; and school days missed decreased 48% to 20%. This program has now become sustainable with both private and Medicaid insurance coverage.     

Providence School Asthma Partnership: School-based Asthma Program for Inner-City Families

Over 3 years, 972 families participated in an after-school asthma program at their child's school. Parents and children attended concurrent 2¹/₂ -hour workshops. Parents were 74% Latino; 45% non-English speaking, with 77% of children on Medicaid. Asthma symptoms were significantly reduced, from multiple times per week to less than once per week on average. Oral steroid use decreased to one third of baseline use. Hospital days decreased from 11% to 2%; emergency visits decreased 35% to 4%; and school days missed decreased 48% to 20%. This program has now become sustainable with both private and Medicaid insurance coverage.     

Asthma Knowledge and Asthma Management Behavior in Urban Elementary School Teachers

Background. Although schools are an important setting for asthma care in youth, teachers’ asthma knowledge and symptom management is poor. This study investigated the knowledge, prevention and management behaviors, and communication regarding asthma of teachers of low-income, ethnic minority students. It was hypothesized that relative to colleagues whose students did not have active asthma (i.e., did not have symptoms during the day), teachers of students with active asthma would have better asthma knowledge and that more would take asthma prevention steps and communicate with parents and school nurses. Methods. Drawing from 25 elementary schools in New York City, 320 pre-Kindergarten through 5th grade classroom teachers with at least one student with asthma completed measures assessing their asthma knowledge, steps taken to manage asthma, communication with the school nurse or parents, information they received about asthma, and whether or not they had at least one student in their class experience asthma symptoms. t test and chi-square were used to test hypotheses. Results. Asthma knowledge varied among teachers. Most could identify potential triggers, yet few knew that medication taken prior to exercise could prevent symptoms and that students with asthma need not avoid exercise. Communication between teachers and school nurses and between teachers and parents was lacking. Relative to colleagues whose students did not have active asthma, teachers whose students had active asthma had better asthma knowledge, more took steps to prevent students from having asthma symptoms, communicated with parents, and more initiated communication with the nurse. Conclusions. Teachers’ knowledge about asthma and asthma management is limited, especially among those whose students did not have active asthma. Teachers respond reactively to students who have symptoms in class by increasing prevention steps and communications with parents and the school nurse. A more proactive approach to managing asthma in schools is warranted.     

Perceived Involvement in Condition Management among Inner-City Youth with Asthma and Their Primary Caregivers

This study examined patterns of agreement versus disagreement in family perceptions of caregiver and youth involvement in asthma management tasks and associations of these patterns with youth asthma outcomes. Fifty-six caregiver-child dyads completed questionnaires of family involvement in asthma management and asthma health outcomes (i.e., symptom days, health care utilization, and medication adherence). Discrepancies were documented for perceptions of both caregiver and youth involvement. Caregiver overestimation of youth involvement in asthma management was associated with greater asthma severity and more asthma symptoms. Discrepancies in family perceptions of involvement pose salient challenges for effective clinical management and require clinical attention.     

Impact of an Adherence Intervention Program on Medication Adherence Barriers,Asthma Control,and Productivity/Daily Activities in Patients With Asthma

Objective. This study evaluated the impact of an asthma patient intervention program, with a focus on medication adherence on adherence barriers, asthma control, and productivity/daily activities. Methods. Patients ≥18 years old who were employed by a large Southeastern public school system, had ≥1 medical claim for asthma, and were taking ≥1 asthma medication were invited to participate in the study. The ASK-20, the Asthma Control Test (ACT), and a productivity questionnaire were administered before and after a 6-month period of intervention that involved the use of baseline ASK-20 results to create patient-specific reports on adherence barriers and talking points for care managers to use during the two outbound telephone calls addressing barriers identified. Patients also received three educational mailings. The ASK-20 is a brief, self-reported instrument developed to identify patient-specific barriers to medication adherence and to improve provider/patient communication about adherence. Results. Of 112 individuals who enrolled, 87 completed the program (77.7%). Participants' mean age was 48.2 years (SD = 10.5), and most were female (86.2%) and white (64.4%). The mean number of years with asthma was 17.5 (SD = 14.7); approximately one third (36.8%) of participants had had asthma for >20 years. The intervention was associated with a significant reduction in the number of adherence barriers (3.8 to 2.8; p = .0021) as well as improvement in asthma control as reflected in an increase in the percentage of participants with controlled asthma defined as having an ACT score > 19 (50.0% to 64.6%; p = .0285). Significant reductions in the mean number of days that housework or schoolwork was limited by asthma (p = .0059) and the mean number of days that family, social, or recreational activities were missed or limited because of asthma (p = .0185) were also observed. The majority of the participants (95%) rated the program as being good, very good, or excellent. Conclusion. Programs incorporating a clinical assessment tool such as the ASK-20 for identifying a broad range of risk factors for nonadherence and for developing patient-specific intervention may reduce adherence barriers and improved disease control and ability to perform daily activities in patients with asthma.