Evaluation of MDI-spacer utilization and technique in caregivers of urban minority children with persistent asthma

Objective: Incorrect Metered-Dose Inhaler (MDI)-spacer technique can result in decreased drug delivery to distal airways and poor asthma outcomes. There is lack of research to examine whether the caregivers utilize proper technique when applying an MDI-spacer delivery system for young minority children with persistent asthma in the United States. The objective of this study was to evaluate MDI-spacer utilization and technique among the caregivers of Bronx minority children with persistent asthma and to determine characteristics associated with correct use. Methods: We analyzed data from 169 caregivers of urban minority children with persistent asthma (aged 2–9 years). MDI-spacer device technique was assessed using a 10-step checklist derived from the national guidelines, literature and manufacturers’ instructions. Based on the median MDI-technique score of six steps demonstrated accurately, caregivers were categorized as correct (seven or more) or incorrect (six or less) users. Results: Of the 169 caregivers, 95% were mothers, mean age 32.3 years (SD 7.6), 56% were unemployed; 74% of the children were Hispanic, 87% had either “not well controlled” or “very poorly controlled” asthma, 92% had a spacer at home and 71% used it “all” or “most” of the time. Only one caregiver correctly demonstrated all 10 steps of the MDI-spacer technique. Child’s having one or more asthma-related hospitalizations in the past 12 months and higher caregiver educational level were independent predictors of correct MDI-spacer technique. Conclusions and relevance: The caregivers of urban, minority children with persistent asthma lack proper MDI-spacer technique, suggesting the potential value of both targeted short- and long-term educational interventions.     

Physician asthma education program improves outcomes for children of low-income families

STUDY OBJECTIVES: To determine whether an interactive physician seminar that has been shown to improve patient/parent satisfaction and to decrease emergency department visits for children with asthma was also effective for those children from low-income families. DESIGN: Seventy-four pediatricians and 637 of their patients were randomized to receive two asthma seminars or no educational programs and were observed for 2 years. SETTING: Physicians in the New York, NY, and Ann Arbor, MI, areas were enrolled, and, on average, 10 patients with asthma per provider were surveyed and observed for 2 years. PATIENTS OR PARTICIPANTS: A total of 637 subjects were enrolled, and 369 subjects remained in the study after 2 years. Of these, 279 had complete medical and survey information. INTERVENTIONS: Physicians were randomized, and then a random sample of their patients was enrolled and surveyed regarding the physician's communication style, the child's asthma symptoms, medical needs, and asthma care. Low income was defined as annual income of < 20,000 dollars. MEASUREMENTS AND RESULTS: The families of 36 children (13%) had an income of < 20,000 dollars, and they were treated by 23 physicians. Low-income children in the treatment group tended to have higher levels of use of controller medications, to receive a written asthma action plan, and to miss fewer days of school, although these differences were not statistically significant compared to low-income children in the control group. However, low-income treatment group children were significantly less likely to be admitted to an emergency department (annual rate, 0.208 vs 1.441, respectively) or to a hospital (annual rate, 0 vs 0.029, respectively) for asthma care compared to children in the control group. CONCLUSIONS: The educational program for physicians improved asthma outcomes for their low-income patients. Provider interventions targeted to these high-risk patients may diminish hospital and emergency department asthma care.     

A systematic review of psychological interventions for children with asthma

AIM: Psychological factors may influence the symptoms and management of asthma in children in many ways. It is, therefore, suggested that psychological interventions may be appropriate for this population. This paper reports a systematic review assessing the efficacy of psychological interventions in improving health outcomes for children with asthma. METHODOLOGY: A review of Randomized Controlled Trials (RCT) was designed. RCTs assessing the effects of a psychological intervention in child participants were included in the review. Outcome measures included healthcare utilization, lung function, asthma symptoms, and psychological health status. The search was conducted until April 2005. RESULTS: Twelve studies, involving 588 children, were included in the review; however, study quality was poor and sample sizes were frequently small. A meta-analysis was performed on two studies, examining the effects of relaxation therapy on PEFR which favored the treatment group (SD 0.82, CI 0.41-1.24). No other meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. In addition, many studies reported insufficient data. CONCLUSIONS: This review was unable to draw firm conclusions for the role of psychological interventions for children with asthma. We recommend that valid outcome measures for evaluating the effectiveness of psychological interventions for children with asthma need to address adjustment to and coping with asthma, as well as other psychological indicators. The absence of an adequate evidence base is demonstrated, highlighting the need for well-conducted RCTs in this area.     

Parental coping,depressive symptoms,and children's asthma control and school attendance in low-income,racially, and ethnically diverse urban families

Objective: Low-income urban children of color are at elevated risk for poor asthma control. This cross-sectional study examined associations among parents' coping (primary control, secondary control, and disengagement), parental depressive symptoms, and children's asthma outcomes (asthma control and school attendance) in a predominantly low-income, racially/ethnically diverse sample of families. Methods: Parents (N = 78; 90% female) of children (33% female; 46% Black; 38% Latino) aged 5–17 years (M = 9.5 years) reported on their own coping and depressive symptoms, their child's asthma control, and full and partial days of school missed due to asthma. Results: Parents' secondary control coping (i.e., coping efforts to accommodate/adapt to asthma-related stressors) was negatively correlated, and disengagement coping (i.e. coping efforts to avoid/detach from stressors) was positively correlated, with their depressive symptoms. Secondary control coping was also correlated with fewer partial days of school missed. Primary control coping (i.e., coping efforts to change stressors) was not associated with depressive symptoms or asthma outcomes. Parents' depressive symptoms were also positively correlated with poorer asthma control and partial days of school missed. Regression models showed direct and indirect effects of secondary control and disengagement coping on asthma outcomes via depressive symptoms, after controlling for demographic factors. Conclusions: Parents' secondary control and disengagement coping are related to children's asthma outcomes. Secondary control coping may support parents' mental health and children's asthma control in low-income urban families.     

Pediatric asthma hospitalizations among urban minority children and the continuity of primary care

Objective: To examine the effect of ambulatory health care processes on asthma hospitalizations. Methods: A retrospective cohort study using electronic health records was completed. Patients aged 2–18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. Results: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09–1.78). Conclusions: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.     

A musculoskeletal outreach screening,treatment, and education program for urban minority children

Purpose. A hospital-based outreach program was initiated to screen minority children in medically underserved areas of New York City for musculoskeletal diseases. We examine the number of such diseases in this population, and evaluate the program's success to facilitate referral and follow-up of children with referral conditions. Methods. Screenings were conducted at schools and day-care centers. Children requiringfurther evaluation were referred to the sponsoring hospital, a major referral center for musculoskeletal diseases. Bilingual educational strategies, transportation reimbursement, and coverage for uninsured children were used to foster participation and increase follow-up. Results. A total of 2,523 children were screened, 168 (6.7%) of whom were referred forone of 45 different musculoskeletal disorders, including scoliosis and back problems, foot problems, in- and out-toeing, knee or hip pain, and problems of joint range of motion. Sixtyseven percent of those referred had a follow-up medical consultation. Conclusions. A substantial proportion of urban minority children have previously undiagnosed musculoskeletal disorders that, if left untreated, have the potential to lead to significant disability in later life. Targeted screening programs can be effective in identifying such disorders, and providing an apportunity for early diagnosis, treatment, and education.     

Home-based rehabilitation interventions for adults living with HIV: a scoping review

Home-based rehabilitation (HBR) has been shown to improve the lives of people living with a wide range of chronic diseases in resource-rich settings. This may also be a particularly effective strategy in resource-poor settings, where access to institution-based rehabilitation is limited. This review aimed to summarise and discuss the evidence related to the effectiveness of home-based rehabilitation (HBR) interventions designed specifically for adults living with HIV. A scoping review methodology was employed, involving systematic search techniques and appraisal of appropriate evidence. English-language journal articles that assessed the quality of life or functional ability outcomes of HBR interventions for adults living with HIV were considered for this review. Out of an initial 1 135 publications retrieved from the search of databases, six articles met this review's inclusion criteria. While this review highlights the scarcity of empirical evidence related to HBR interventions for adults living with HIV, the findings of these six articles are that HBR is a safe management option that may confer a number of physical and psychological benefits for this population. Future research on HBR interventions should include a wider range of assessment measures, including cost-benefit analyses and specific tools designed to assess the functional ability and participation in activities of daily living of participants involved in these programmes. In particular, more research on HBR is required in resource-poor environments, such as sub-Saharan Africa where HIV is endemic, to assess whether this is a feasible strategy that is both effective and practical in the areas that may need it most.     

HIV testing among racial and ethnic minority adolescents living in an urban community

ABSTRACT

This study examined the factors that influence HIV testing among a sample of African American and Hispanic/Latino adolescents (N?=?747) living in an economically disadvantaged community in the Northeastern United States. The majority of sexually active participants in our study (77%) have never been tested for HIV. However, youth engaging in risky sexual behaviors, interacting in positive peer networks, and having access to sources of prevention information were more likely to seek HIV testing services. Our findings underscore the importance of developing multifaceted HIV/AIDS prevention protocols that provide direct education and skill-building activities, leverage peer education as a means to disseminate health-related information, and deliver broad-based prevention messaging that is both culturally-tailored and gender-specific.     

The association of childhood asthma with mental health and developmental comorbidities in low-income families

Objective: The objective of the study was to determine the relationship of childhood asthma with mental health and developmental indicators in low-income families. Methods: Parents/guardians of approximately 400 children, aged 2–14 years, were recruited from a charity hospital serving low income neighborhoods in the outskirts of Karachi, Pakistan. Mothers of children were interviewed in their local language by a trained nurse. Eight self-reported comorbidities were grouped into two constructs based on factor analysis and conveniently labeled as mental health (anxiety, attention and behavioral problems) and developmental problems (learning, developmental delay, hearing impairment, sleep and speech problems). Data were analyzed using multiple logistic regression, adjusted for age, sex, presence of older siblings, number of people in the household, child birth weight, presence of mold, and family history of asthma or hay fever. Results: Children with asthma had 18 times greater odds of mental health problems (adjusted OR?=?18.0, 95% CI: 9.2, 35.1) as compared to children without asthma. The odds of developmental problems were more than 14 times greater for children with asthma (adjusted OR?=?14.3, 95% CI: 7.8, 26.1) as compared to children without asthma. Conclusions: This study found mental and developmental adverse consequences of childhood asthma in low-income families. Identifying and treating asthma at an early age could reduce the burden of comorbidities in this population.     

A systematic and methodological review of interventions for young people experiencing alcohol-related harm

Aims This review identified published studies evaluating interventions delivered outside educational settings, designed for young people with existing alcohol use problems, or who participate in behaviour that places them at high risk of alcohol‐related harm, critiqued their methodology and identified opportunities for new interventions. Methods A systematic search of the peer‐reviewed literature interrogated 10 electronic databases using specific search strings, limited to 2005–09. No additional studies were found by a librarian searching other collections and clearing‐houses, or by hand‐searching review paper reference lists. The 1697 articles identified were reviewed against criteria from the Dictionary for the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Results The methodological quality of existing studies is variable, and needs to be both more rigorous and more consistent. Particular problems include the lack of blinding outcome assessors, a reliance solely on self‐report measures, highly variable consent and follow‐up rates, infrequent use of intention‐to‐treat analyses and the absence of any economic or cost analyses. The range of interventions evaluated is currently limited to individually focused approaches, almost exclusively implemented in the United States. Conclusions There is a great need for more intervention trials for young people at high risk of experiencing alcohol‐related harm that are both methodologically rigorous and have a broader community focus, to complement the psychological interventions that currently dominate the relevant literature. Such trials would improve outcomes for high‐risk young people themselves and would improve the evidence base, both in their own right and by facilitating future meta‐analyses.     

Strategies to improve antiretroviral therapy (ART) initiation and early engagement among men in sub-Saharan Africa: A scoping review of interventions in the era of universal treatment

Objectives

Men in sub-Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented.

Methods

Three databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016–2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non-standard service delivery strategy), and written in English.

Results

Of the 4351 sources retrieved, 15 (reporting on 16 interventions) met inclusion criteria. Of the 16 interventions, only two (2/16, 13%) exclusively focused on men. Five (5/16, 31%) were randomised control trials (RCT), one (1/16, 6%) was a retrospective cohort study, and 10 (10/16, 63%) did not have comparison groups. Thirteen (13/16, 81%) interventions measured ART initiation and six (6/16, 37%) measured early retention. Outcome definitions and time frames varied greatly, with seven (7/16, 44%) not specifying time frames at all. Five types of interventions were represented: optimising ART services at health facilities, community-based ART services, outreach support (such as reminders and facility escort), counselling and/or peer support, and conditional incentives. Across all intervention types, ART initiation rates ranged from 27% to 97% and early retention from 47% to 95%.

Conclusions

Despite years of data of men's suboptimal ART outcomes, there is little high-quality evidence on interventions to increase men's ART initiation or early retention in SSA. Additional randomised or quasi-experimental studies are urgently needed.     

Increased identification of the primary care provider as the main source of asthma care among urban minority children

Objective: Urban, minority, and disadvantaged youth with asthma frequently use emergency departments (EDs) for episodic asthma care instead of their primary care providers (PCPs). We sought to increase the rate of guardians' identification of the PCP as the source of asthma care for their children through integrated electronic health records and care coordination. Methods: In this prospective cohort study, we implemented an electronic communication process between an asthma specialty clinic and PCPs coupled with short-term care coordination in sample of youth aged 2–12 years with asthma and surveyed their guardians at baseline and 3 and 6 months after the intervention. Results: Guardians of 50 children (median age 5.8 years, 64% male, 98% African American, 94% public insurance) were enrolled. Compared to baseline, at 3 and 6 months after the intervention, significantly more guardians reported that the PCP was their child's primary asthma health care provider [70% at baseline, 85% at 3 months, 83% at 6 months (time averaged adjusted OR 77.4, 95% CI 3.0, 2027.1]. Further, significantly more guardians reported that they took their child to the PCP when the child experienced problems with his/her asthma [16% at baseline, 35% at 3 months, 41% at 6 months (time averaged adjusted odds ratio (OR) 10.6, 95% CI 2.7, 41.7]. Conclusion: Care in a subspecialty asthma clinic augmented by electronic communication with PCPs and short term care coordination was associated with significantly improved identification of PCPs as the primary source of asthma care in a cohort of urban minority youth.     

Technologies for Diabetes Self-Monitoring: A Scoping Review and Assessment Using the REASSURED Criteria

Background:Self-management is an important pillar for diabetes control and to achieve it, glucose self-monitoring devices are needed. Currently, there exist several different devices in the market and many others are being developed. However, whether these devices are suitable to be used in resource constrained settings is yet to be evaluated.Aims:To assess existing glucose monitoring tools and also those in development against the REASSURED which have been previously used to evaluate diagnostic tools for communicable diseases.Methods:We conducted a scoping review by searching PubMed for peer-review articles published in either English, Spanish or Portuguese in the last 5 years. We selected papers including information about devices used for self-monitoring and tested on humans with diabetes; then, the REASSURED criteria were used to assess them.Results:We found a total of 7 continuous glucose monitoring device groups, 6 non-continuous, and 6 devices in development. Accuracy varied between devices and most of them were either invasive or minimally invasive. Little to no evidence is published around robustness, affordability and delivery to those in need. However, when reviewing publicly available prices, none of the devices would be affordable for people living in low- and middle-income countries.Conclusions:Available devices cannot be considered adapted for use in self-monitoring in resource constraints settings. Further studies should aim to develop less-invasive devices that do not require a large set of components. Additionally, we suggest some improvement in the REASSURED criteria such as the inclusion of patient-important outcomes to increase its appropriateness to assess non-communicable diseases devices.     

Medication use,sleep, and caregiver smoking status among urban children with asthma

Objective: Children living in urban settings from low-income, minority families are at a high risk for experiencing asthma morbidity. Environmental tobacco smoke (ETS, i.e., secondhand) exposure, typically from caregiver smoking, has been associated with increased quick-relief medication use and child nocturnal awakenings due to increased asthma symptoms as well as worse sleep quality in children with asthma. This study investigated the moderating role of caregiver smoking status on the association between quick-relief medication use and child's sleep quality in urban children with persistent asthma. Methods: Fifty-four urban children with persistent asthma and their primary caregivers completed a baseline research session. Caregivers then completed ecological momentary assessment surveys via smartphones twice daily for two weeks in which smoking behaviors, child quick-relief medication use, and child's sleep quality were assessed. Results: Twenty caregivers (37%) reported smoking at least one day across the two-week period. The caregiver smoking status significantly moderated the association between quick-relief medication use and child's sleep quality after controlling for child age and monthly household income. The caregiver smoking status exacerbated the association between quick-relief medication use and child's sleep quality, such that more medication usage was associated with worse sleep quality. Conclusions: Findings suggest that in urban families with a caregiver who smokes, more daily quick-relief medication use may put children at an increased risk for worse sleep quality. The effects of ETS exposure on child's sleep quality in addition to child asthma symptoms should be an integral part of discussions between pediatric healthcare providers and families of children with asthma.     

A pilot randomized trial of school-based administration of inhaled corticosteroids for at-risk children with asthma

Objective: To investigate whether high adherence to inhaled corticosteroids (ICS) among disadvantaged urban public school children on public insurance with persistent asthma is achievable by having school nurses administer morning doses on each day that school is in session. Design/methods: This was a pilot prospective randomized clinical trial of home versus school nurse-administered ICS among children on Medicaid enrolled in grades K-8. The primary outcome was the proportion of expected morning doses of ICS given to the intervention group in school over the 60-day treatment period. Secondary outcomes included the relative proportions of expected doses (morning, evening, and total), asthma-related morbidity, quality of life, and health-care utilization. Results: A total of 46 patients were enrolled (mean age 8.21 ± 2.45; 56.5% male; 91.3% non-Hispanic, African-Americans), and follow-up data were available for 44/46 (95.7%) patients. The groups did not differ in age, gender, race/ethnicity, or asthma severity. The intervention group received 91.7% of expected morning doses of ICS at school over the 60-day treatment period (95% CI [87.7, 95.5]). Intervention patients reported significantly less functional limitation (42.9% vs. 73.9%, p = 0.04), adjustment to family life (23.8% vs. 56.5%, p = 0.03), and sleep loss (1.7 vs. 4.1 nights in last 2 weeks, p = 0.035) than control patients at the end of the 60-days study period. There were no differences in unscheduled health-care utilization by group. Conclusions: These pilot data suggest that school-based administration of ICS has the potential to achieve high adherence to morning doses of ICS on school days among urban, disadvantaged, and largely minority children with asthma.     

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children

Objectives: To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children. Methods: We prospectively enrolled 2–10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP “Acute Asthma” visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP. Results: One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5?±?2.3 (standard deviation), range 0–10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2?±?2.8; range 1–18. The mean number of PCP Acute Asthma visits/child was 0.7?±?1.6; range 0–11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI ?0.018, 0.06). Conclusions: Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.