Asthma medication adherence among urban teens: a qualitative analysis of barriers,facilitators and experiences with school-based care

Objective: Teens with persistent asthma do not always receive daily preventive medications or do not take them as prescribed, despite established clinical guidelines. The purpose of this study was to understand urban teens’ experiences with asthma management, preventive medication adherence and participation in a school-based intervention. Methods: Teens (12–15 years) with persistent asthma, and prescribed preventive medication, participated in a pilot study that included daily observed medication therapy at school and motivational interviewing. Semi-structured interviews occurred at final survey. Qualitative content analysis enabled data coding to identify themes. Results: Themes were classified as “general asthma management” or “program-specific.” For general management, routines were important, while hurrying interfered with taking medications. Forgetfulness was most commonly linked to medication nonadherence. Competing demands related to school preparedness and social priorities were barriers to medication use. Independence with medications was associated with several benefits (e.g. avoiding parental nagging and feeling responsible/mature). Program-specific experiences varied. Half of teens reported positive rapport with their school nurse, while a few felt that their nurse was dismissive. Unexpected benefits and barriers within the school structure included perceptions about leaving the classroom, the distance to the nurse’s office, the necessity of hall passes and morning school routines. Importantly, many teens connected daily medication use with fewer asthma symptoms, incenting continued adherence. Conclusions: Teens with asthma benefit from adherence to preventive medications but encounter numerous barriers to proper use. Interventions to improve adherence must accommodate school demands and unique teen priorities. The school nurse’s role as an ally may support teens’ transition to medication independence.     

Student perspectives on asthma management in schools: a mixed-methods study examining experiences,facilitators, and barriers to care

Objective: Children spend nearly a third of their day at school, making it a critical point of intervention for those with asthma. This study aimed to illuminate minority students’ experiences with asthma at school and perceptions of facilitators and barriers to care. Methods: A mixed-methods study was conducted with elementary students with asthma. Participants completed a 24-question survey, drawing exercise to depict experiences caring for their asthma at school, and focus group discussion. Drawings were analyzed for narrative and pictorial themes. Discussions were audio-recorded, transcribed, and independently coded for themes. Results: Fifteen children with asthma (8–11?years) participated from two Chicago schools with predominately African-American populations. Most students (79%) indicated they had control of asthma at school, while 85% identified asthma as a problem when exercising. Half (53%) received help with asthma care at school. Drawings depicted cooperative management with adults or peers and the central role of inhalers as part of everyday asthma care in school. Finally, focus groups produced six key themes within the domains of facilitators: 1) support of others, 2) self-efficacy; 3) perception of being normal; and barriers: 4) lack of support from others; 5) difficulty accessing inhaler; 6) perception of being different. Conclusions: This study suggests asthma care plays an important role in students’ school experiences. Stigma around inhaler use, lack of concern by school staff, and limited access to medications remain as barriers to school-based asthma management. Although facilitators, such as support from teachers and peers, do exist, future interventions must address existing barriers.     

A web-based, tailored asthma management program for urban African-American high school students

RATIONALE: Urban African-American youth, aged 15-19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing. OBJECTIVES: Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses "tailoring," in conjunction with theory-based models, to alter behavior through individualized health messages based on the user's beliefs, attitudes, and personal barriers to change. METHODS: High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers. MEASUREMENTS AND MAIN RESULTS: Functional status and medical care use were measured at study initiation and 12 months postbaseline, as were selected management behaviors. The intervention period was 180 days (calculated from baseline). A total of 314 students were randomized (98% African American, 49% Medicaid enrollees; mean age, 15.2 yr). At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students; adjusted relative risk and 95% confidence intervals were as follows: 0.5 (0.4-0.8), p = 0.003; 0.4 (0.2-0.8), p = 0.009; 0.3 (0.1-0.7), p = 0.006; 0.5 (0.3-0.8), p = 0.02; and 0.2 (0.2-0.9), p = 0.01, respectively. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per participating treatment group student. CONCLUSIONS: A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population.     

老年HIV感染者运动促进与障碍因素的质性研究

目的 描述老年HIV感染者运动的促进与障碍因素,为制订相应的运动促进项目提供依据.方法 本研究为描述性质性研究,采用便利抽样和目的 抽样法选取2020年7月至2021年1月上海市艾滋病定点诊疗机构艾滋病门诊的老年HIV感染者12名进行半结构式访谈.采用传统内容分析和归纳式内容分析法分析资料.结果 12名访谈对象中男性8...     

Breathing retraining for African-American adolescents with asthma: a pilot study of a school-based randomized controlled trial

Objective: Asthma affects approximately seven million children/adolescents in the USA, with African-American children disproportionately affected. Breathing retraining techniques have been shown to improve asthma outcomes in adults, though research in youth is limited. The purpose of this pilot study was to test the feasibility and preliminary efficacy of a school-based randomized controlled trial of breathing retraining for asthma outcomes and anxiety symptoms in a sample of urban, African-American adolescents. Methods: Adolescents were randomized into either the intervention group (20-min breathing retraining plus education) or control group (20-min standard education). Participants completed two study visits, one month apart. Asthma control, asthma quality of life and lung functioning (FEV1 and peak flow) were the primary outcomes, and state anxiety (pre-post the intervention) and trait anxiety (over the one-month period) were the secondary outcomes. Results: Thirty-three African-American adolescents participated in the study, with a 90% retention rate between visit 1 and visit 2. Asthma control and asthma quality of life, significantly improved over time (p?≤?0.01) with no differences between intervention and control groups. State anxiety significantly decreased (p?≤?0.01) immediately post intervention at both time points with no differences between groups. There were no significant differences found in lung functioning or trait anxiety over the one-month time period. Conclusions: These preliminary results suggest that breathing retraining is a feasible, acceptable and potentially efficacious intervention (although no significant differences between groups were found) for improving asthma symptoms in urban adolescents with asthma in a school-based setting.     

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.     

Reduced risk of physician-diagnosed asthma among children dwelling in a farming environment

BACKGROUND AND OBJECTIVE: Living in a farm environment has been reported to be associated with lower prevalence of asthma, based on the results of cross-sectional studies. The objective of this longitudinal study was to determine whether living in a farm environment is associated with lower incidence of asthma among children. METHODS: A total of 13 524 asthma-free children aged 0-11 years were drawn from the Cycle 1 (1994/1995) of the Canadian National Longitudinal Survey of Children and Youth (NLSCY). Subjects were categorized as dwelling in rural farming, rural non-farming and non-rural environments. Incidence of physician-diagnosed asthma was determined at Cycle 2 (1996/1997). Bootstrap logistic regression method was used to adjust for design effect in the NLSCY. RESULTS: The 2-year cumulative incidence of asthma was 2.3%, 5.3% and 5.7% among children living in farming, rural non-farming and non-rural environments, respectively. From the multivariate analysis with adjustment for important confounders, children from a farming environment had a reduced risk of asthma compared with children from rural non-farming environment with odds ratios (OR) of 0.22 (95% CI: 0.07-0.74) and 0.39 (95% CI: 0.24-0.65) for children with and without parental history of asthma, respectively. Children living in a non-rural environment with parental history of asthma had an increased risk of asthma incidence when compared with children living in rural non-farming environment (OR = 2.51, 95% CI: 1.56-4.05). CONCLUSION: This longitudinal study expands on observational study results which suggest a reduced risk of developing asthma associated with living in a farming environment.     

Relationship of medical home quality with school engagement and after-school participation among children with asthma

Objectives: To examine the relationship between medical home quality and measures of daily life experiences among children with asthma. Methods: A nationally representative sample of children from the 2007 National Survey of Children's Health (NSCH), aged 6–17 years (n = 6357), who have asthma was used to assess the relationship of a quality medical home and its features with their daily life experiences. Five medical home features – access, continuity, comprehensiveness, family-centered care, and coordination of care – were examined individually and in total in relation to measures of school engagement (missed school days, parents contacted about problems with the child, repeating a grade since kindergarten) and after-school activity participation (physical activity, sports participation, and community service or volunteer work). Results: Before and after adjustment for personal characteristics, health insurance status, family environment, neighborhood variables, and asthma severity, total medical home score was associated with more days exercised [beta (B) = 0.10, p < .05] and a greater likelihood of having performed community service or volunteer work [odds ratio (OR) = 1.16, CI: 1.02–1.31]. Additionally, the medical home features of access, comprehensiveness, and family-centered care remained favorably associated with three of the six measures of school engagement and after-school activity participation, even after adjustment. Conclusion: Medical home quality – particularly the features of access, comprehensiveness, and family-centered care – is positively associated with the daily life experiences of children with asthma. Working to enhance these aspects of primary care might be one place to start in improving the management of children's chronic conditions and their quality of life.     

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.     

Prevalence and factors associated with hypertension among school children and adolescents in urban and semi‐urban areas in Cameroon

Few data to date exist on pediatric hypertension (PH) prevalence and risk factors in semi‐urban areas in Cameroon, and they are believed to be the same as urban areas. These data are needed to design targeted preventive strategies and contribute to reducing the burden of PH in Cameroon and countries with equivalent standards of care. The authors conducted a cross‐sectional study, from November, 2017 to June, 2018, in primary and secondary schools, from semi‐urban (Bamboutos, West Region) and urban (Mfoundi, Center Region) settings in Cameroon, including children and adolescent aged between 3 and 19 years, recruited on a stratified probability sampling. PH was defined according to the American Academy of Pediatrics 2017. Overall, 1001 and 842 participants were, respectively, included in urban and semi‐urban areas. The overall average age was 13.9 ± 4.03 years, and two‐thirds were girls. Overweight and obesity were more prevalent in urban area (overweight: 17.1%; obesity: 5.9%), compared to semi‐urban (overweight: 1.1% and obesity: 0.8%) (p < .001). The prevalence of hypertension was higher in urban (12%) than semi‐urban areas (8.6%) (p = .01). We have identified as factors associated with PH: age > 14 years (OR = 3.18 [1.6; 6.2]) and secondary level of education (OR = 2.5 [1.2; 5.5]) in urban areas; family history of hypertension (OR 1.93 [1.1; 3.4] in semi‐urban areas. PH prevalence is higher in urban than semi‐urban areas, and the associated factors are not the same. Policies to address hypertension in the pediatric population must be targeted and tailored to the different population profiles.     

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma

Objective: Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. Methods: Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2–18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. Results: None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ² = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ² = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children. Conclusions: The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.     

Knowledge,barriers and facilitators of exercise in dialysis patients: a qualitative study of patients,staff and nephrologists

Background

Despite growing evidence on benefits of increased physical activity in hemodialysis (HD) patients and safety of intra-dialytic exercise, it is not part of standard clinical care, resulting in a missed opportunity to improve clinical outcomes in these patients. To develop a successful exercise program for HD patients, it is critical to understand patients’, staff and nephrologists’ knowledge, barriers, motivators and preferences for patient exercise.

Methods

In-depth interviews were conducted with a purposive sample of HD patients, staff and nephrologists from 4 dialysis units. The data collection, analysis and interpretation followed Criteria for Reporting Qualitative Research guidelines. Using grounded theory, emergent themes were identified, discussed and organized into major themes and subthemes.

Results

We interviewed 16 in-center HD patients (mean age 60 years, 50% females, 63% blacks), 14 dialysis staff members (6 nurses, 3 technicians, 2 dietitians, 1 social worker, 2 unit administrators) and 6 nephrologists (50% females, 50% in private practice). Although majority of the participants viewed exercise as beneficial for overall health, most patients failed to recognize potential mental health benefits. Most commonly reported barriers to exercise were dialysis-related fatigue, comorbid health conditions and lack of motivation. Specifically for intra-dialytic exercise, participants expressed concern over safety and type of exercise, impact on staff workload and resistance to changing dialysis routine. One of the most important motivators identified was support from friends, family and health care providers. Specific recommendations for an intra-dialytic exercise program included building a culture of exercise in the dialysis unit, and providing an individualized engaging program that incorporates education and incentives for exercising.

Conclusion

Patients, staff and nephrologists perceive a number of barriers to exercise, some of which may be modifiable. Participants desired an individualized intra-dialytic exercise program which incorporates education and motivation, and they provided a number of recommendations that should be considered when implementing such a program.