Determinants of asthma control among children in Saudi Arabia

Objective: Asthma is the most common chronic disease among children. Uncontrolled asthma may considerably decrease the quality of life for patients and their families. Our objective was to identify possible risk factors for poor asthma control in children. Methods: A cross-sectional study was conducted among children with asthma aged 4–11?years who attended a pediatric clinic for follow-up visits at one of the major teaching hospitals in Riyadh, Saudi Arabia. Asthma control status was measured by the childhood asthma control test. Multiple logistic regression analysis was performed to explore the relationships between the outcome and exposure variables. Results: Uncontrolled asthma was present in 89 out of 158 children (59.3%). Asthma control improved with the number of siblings. Control improved by 69% with two or three siblings (OR?=?0.31, 95% CI?=?0.10–0.96) and by 87% with four or more siblings (OR?=?0.13, 95% CI?=?0.04–0.48). Similarly, asthma control improved with an increased asthma knowledge of the caregiver (OR?=?0.87, 95% CI?=?0.81–0.93). Household incomes less than SAR 15?000 and sharing a bedroom increased the odds of having uncontrolled asthma by 2.30 (95% CI?=?1.02–5.21) and 3.33 (95% CI?=?1.33–8.35), respectively. Conclusions: In addition to knowledge, socioeconomic factors, such as family income, household crowding, and the number of siblings are associated with asthma control among children in Saudi Arabia. Further research is needed to investigate the role of these factors.     

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.     

Concordance among children,caregivers, and clinicians on barriers to controller medication use

Objective: While much research has addressed asthma medication adherence, few have combined quantitative and qualitative data, and none has addressed the triad of child, caregiver, and clinician simultaneously. This study assessed, with mixed methods, barriers to medication adherence within this triad. Methods: We conducted interviews with publicly-insured children with asthma, their caregivers, and their primary-care clinicians. Children (7–17 years) had been prescribed daily inhaled corticosteroids and visited the ED for asthma (past year). Participants answered open-ended and survey questions, rating suggested barriers to medication use (never vs. ever a barrier). McNemar's tests compared report of barriers by each group (children, caregivers, clinicians), and assessed concordance within triads. Results: Fifty child–caregiver dyads participated (34 clinicians). Children (40% female; median age 10 years) had mostly non-Hispanic black (90%) caregivers with less than or equal to high-school education (68%). For barriers, children and clinicians were more likely than caregivers to report medications running out. Clinicians were also more likely to cite controllers being a “pain to take” (vs. children) and forgetfulness (vs. caregivers) (all p < .05). There was a lack of within-triad concordance regarding barriers to adherence, especially regarding medication running out, worrying about taking a daily medication, and medication being a pain to take. Qualitative data revealed themes of competing priorities, home routines, and division of responsibility as prominent contributors to medication adherence. Conclusions: There was significant disagreement among children, caregivers, and clinicians regarding barriers to daily use of asthma medications. To tailor asthma management conversations, clinicians should understand family-specific barriers and child–caregiver disagreements.     

The relationship between patient–provider communication and quality of life for children with asthma and their caregivers

Abstract

Objective: This study examined whether patient–provider communication is associated with asthma-related quality of life (QOL) and asthma outcomes among children with asthma and their caregivers. Methods: Children ages 8–16 years with asthma and their caregivers (n?=?296) were recruited at five pediatric practices in North Carolina. Children and caregivers reported demographic and clinical characteristics immediately after an audio-taped medical visit with their health care provider. During a home visit that took place 1 month after the medical visit, children and caregivers reported asthma-related QOL, and caregivers reported child asthma outcomes, including asthma symptom days and missed school days. Generalized estimating equations were used to determine whether patient–provider communication during the medical visit was associated with child and caregiver QOL and child asthma outcomes 1 month later. Results: On average, providers asked caregivers 4.5 questions and asked children 3 questions per visit, whereas caregivers and children asked less than 1 question per visit. Providers asked children more asthma-related questions, caregivers reported better QOL and fewer asthma symptom days 1 month later. Children and caregivers with higher asthma-management self-efficacy at the office visit reported better QOL 1 month later. Conclusions: Mirroring national guideline recommendations, our results suggest that providers should ask children about their asthma during medical visits. Future longitudinal studies should conduct mediation analyses to determine whether asking children asthma-related questions during medical visits increases children’s asthma management self-efficacy and ultimately improve outcomes, such as QOL, health care utilization, symptom days and missed school days.     

Family caregivers' reported nonadherence to the controller medication of asthma in children in Casablanca (Morocco): Extent and associated factors

Objective: Recent statistics show a relatively high prevalence of asthma among Moroccan children and a weak control over their symptoms. To our knowledge, no research has been carried out to document adherence to the controller treatment in this population. This study aims 1) to assess the extent of children's nonadherence to the controller treatment of asthma in an urban region of Morocco as reported by a family caregiver, and 2) to identify the associated factors. Methods: We conducted a cross-sectional study among caregivers of asthmatic children (2–12 years old) in different health and education facilities of Casablanca-Settat. We administered face-to-face questionnaires incorporating validated instruments (Medication Adherence Rating Scale-Asthma (MARS-A), Beliefs about Medicines Questionnaire (BMQ), Asthma Knowledge Questionnaire). Univariate and multivariate log-binomial regressions evaluating the association between several factors and reported nonadherence were performed (prevalence ratios (PR) and 95% confidence intervals (CI)). Results: Through two public hospitals, three private medical clinics, and one private school, 103 caregivers were recruited. Low adherence to the controller treatment of asthma was reported by 48% of the caregivers (MARS-A <45). In the multivariate model, caregivers with the lowest level of knowledge about asthma were almost three times more likely to report low adherence compared to caregivers with the highest level (PR = 2.93; 95% CI: 1.14–7.52). Conclusions: This study highlights the finding that low adherence is widespread in this context and also the importance of targeting caregivers' knowledge of asthma for interventions.     

Goals,Beliefs, and Concerns of Urban Caregivers of Middle and Older Adolescents with Asthma

Objective: Caregiver goals, an integral part of a partnership for asthma management, have been found to influence asthma outcomes in children. These goals are likely to change during the transitional period of adolescence to address the needs of teenagers as they mature and assume greater responsibilities for their own care. Little is known about the goals, beliefs, and concerns of caregivers as they begin to shift responsibilities for asthma management to teens. This study sought to identify the asthma management goals, beliefs, and concerns of primarily African American caregivers of urban middle and older adolescents. Methods: Fourteen caregivers of urban African American adolescents aged 14–18 years with asthma participated in a focus group session. An iterative process was used to identify themes from the session related to asthma management goals, concerns, and beliefs of caregivers. Results: Caregivers identified goals that related to supporting their teens’ progress toward independent asthma self-management. They described significant concerns related to the teens’ ability to implement asthma self-management, especially in school settings. Caregivers also revealed beliefs that represented knowledge deficits related to asthma medications and factors that improved or worsened asthma. Most caregivers identified grave concerns about school policies regarding asthma medication administration and the lack of knowledge and support provided by teachers and staff for their teen. Conclusion: Caregivers are an invaluable resource in the care of adolescents with asthma. An opportunity exists to improve caregiver understanding of asthma medications and to provide support through improvements in asthma care for adolescents in school-based settings.     

The impact of limited English proficiency on asthma action plan use

Objective: The goal of this study was to compare rates of asthma action plan use by limited English proficiency (LEP) caregivers to English proficient (EP) caregivers. Methods: A cross-sectional bilingual survey was distributed at an urban, academic, pediatric emergency department (PED). Surveys were completed by adult caregivers of children with asthma who sought PED care for asthma related chief complaints. LEP was defined as caregiver ability to speak English less than “very well”. Data were analyzed using Fisher’s exact test and odds ratios (OR). Results: One hundred seven surveys were completed and analyzed. Fifty-one surveys (48%) were completed by LEP caregivers and 56 (52%) by EP caregivers. A 25% difference (p?=?.01) in action plan use rates between LEP caregivers (39%) and EP caregivers (64%) was observed. EP alone was associated with action plan use (OR 2.8 [95% CI 1.3–6.1]). Variables not associated with plan use included mother acting as caregiver (OR 2.1 [95% CI 0.7–7.0]), age of child >7 years (OR 1.0 [95% CI 0.5–2.4]), caregiver education?≥?associate degree (OR 1.4 [95% CI 0.6–3.0]), private insurance (OR 0.7 [95% CI 0.3–1.8]), White race (OR 0.7 [95% CI 0.2–2.2]), Latino ethnicity (OR 0.5 [95% CI 0.2–1.3]) and a federally qualified health center (OR 0.8 [95% CI 0.3–2.0]). The main caregiver reasons for plan use were feeling that a plan works/gets results, helps with symptom management and appreciation towards physician attentiveness when a plan is prescribed. The main caregiver reasons for non plan use were they were not informed/given an action plan or perceived the child’s asthma as mild/well controlled. Conclusion: Compared with EP caregivers, those with LEP experience disparate rates of asthma action plan use.     

Factors associated with adolescent and caregiver reported problems in using asthma medications

Objectives: The purpose of this study was to: (a) describe the types of medication problems/concerns youth with asthma and their caregivers reported and (b) examine the association between sociodemographic characteristics and youth and caregiver reported medication problems/concerns. Methods: English- and Spanish-speaking youth ages 11–17 with persistent asthma were recruited at four pediatric clinics. Youth were interviewed and caregivers completed questionnaires about reported asthma medication concerns/problems. Multiple logistic regression was used to analyze the data. Results: Three hundred and fifty-nine youth were recruited. Eighty percent of youth and 70% of caregivers reported one or more problems in using asthma medications. The most commonly reported problems by youth were: (a) hard to remember when to take the asthma medication (54%) and (b) hard to use asthma medication at school (34%). Younger children were significantly more likely to report difficulty in understanding their asthma medication's directions and difficulty reading the print on the medication's package. Caregivers’ top-reported problem was that it is hard for their child to remember to take their asthma medications (49%). Caregivers without Medicaid were significantly more likely to express difficulty paying for their child's asthma medications. Conclusions: Difficulty remembering to take asthma medication was a significant problem for youth and their caregivers. Providers should work with youth and their caregivers to identify asthma medication problems and discuss strategies to address those problems.     

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.     

Barriers to Asthma Management Among Urban Families: Caregiver and Child Perspectives

Objective. Asthma is one of the most common chronic diseases of childhood. Those particularly affected are young, poor, African American children. Moreover, rates of emergency department visits, hospitalizations, and mortality are substantially higher for black children. Despite the ample published research on asthma prevalence and asthma management interventions, there is little research available on barriers to asthma care among urban, low-income families as perceived by children with asthma and their caregivers. Methods. This qualitative study analyzed data from five focus groups conducted with 28 participants in metropolitan Atlanta. Results. This study found caregiver and child health beliefs and perceptions concerning the use of daily controller medications to be a significant barrier to asthma care and proper self-management at home and at school. Barriers to environmental control consisted mostly of financial constraints, which made residential environmental remediation activities difficult to implement. Psychological distress was prevalent among both children and caregivers, which demonstrated the burden associated with managing a chronic illness. Conclusion. Families in urban, low-income communities require asthma management interventions tailored to their specific characteristics, barriers, and challenges. Our findings can be used to inform and enhance asthma management interventions for urban families with children with asthma.     

Assessing health outcomes,quality of life,and healthcare use among school-age children with asthma

Objective: Asthma affects six million children in the United States. Most people can control their asthma symptoms with effective care, management, and appropriate medical treatment. Information on the relationship between asthma control and quality of life indicators and health care use among school-age children is limited. Methods: Using the 2006–2010 combined Behavior Risk Factor Surveillance System Asthma Call-back Survey child data, we examined asthma control and asthma attack status among school-age (aged 5–17 years) children with asthma from 35 states and the District of Columbia. Multivariable logistic regression models were used to assess if having uncontrolled asthma and having ≥1 asthma attacks affect quality of life (activity limitation and missed school days) and healthcare use (emergency department [ED] visits and hospitalizations). Results: About one-third (36.5%) of the 8,484 respondents with current asthma had uncontrolled asthma and 56.8% reported ≥1 asthma attack in the past year. Having uncontrolled asthma and having ≥1 asthma attack were significantly associated with activity limitation (aPR = 1.43 and 1.74, respectively), missed school (1.45 and 1.68), ED visits (2.05 and 4.78), and hospitalizations (2.38 and 3.64). Long-term control (LTC) medication use was higher among respondents with uncontrolled asthma (61.3%) than respondents with well-controlled asthma (33.5%). Conclusions: Having uncontrolled asthma is associated with reduced quality of life and increased health care use. However, only 61.3% of respondents with uncontrolled asthma use LTC medications. Increasing use of LTC medications among children with uncontrolled asthma could help improve quality of life and reduce health care use.     

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.     

Long-term control medication use and asthma control status among children and adults with asthma

Background: Uncontrolled asthma decreases quality of life and increases health care use. Most people with asthma need daily use of long-term control (LTC) medications for asthma symptoms and to prevent asthma attacks. Ongoing assessment of a person's level of asthma control and medication use is important in determining the effectiveness of current treatment to decrease the frequency and intensity of symptoms and functional limitations. Objective: To assess the use of LTC medication among children and adults with current asthma and identify contributing factors for LTC medication use. Methods: We used the 2006–2010 Behavioral Risk Factor Surveillance System (BRFSS) child and adult Asthma Call-back Survey (ACBS) data to assess the level of asthma control and LTC medication use. Asthma control was classified as well controlled and uncontrolled using guideline-based measures. We used multivariable logistic regression models to identify contributing factors for LTC medication use and having uncontrolled asthma. Results: Among persons with current asthma, 46.0% of children and 41.5% of adults were taking LTC medications and 38.4% of children and 50.0% of adults had uncontrolled asthma. Among children who had uncontrolled asthma (38.4%), 24.1% were taking LTC medications and 14.3% were not taking LTC medications. Among adults who had uncontrolled asthma (50.0%), 26.7% were taking LTC medications and 23.3% were not taking LTC medications. Conclusions: Using BRFSS ACBS data to assess the level of asthma control and LTC medication use can identify subpopulations of persons with asthma who receive suboptimal treatment, for which better asthma-related medical treatment and management are needed.     

A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers

Objectives: To evaluate limited English proficiency (LEP) Latino caregiver asthma knowledge after exposure to an educational video designed for this target group. Methods: A cross-sectional, interventional study was performed. We aimed to evaluate the post-test impact on asthma knowledge from baseline after exposure to a patient-centered, evidence-based, and professionally produced Spanish asthma educational video. Participants included LEP Latino caregivers of children 2–12 years old with persistent asthma. Enrollment was performed during ED encounters or scheduled through a local community organization. Asthma knowledge was measured with a validated Spanish parental asthma knowledge questionnaire. Differences in mean scores were calculated with a paired t-test. Results: Twenty caregivers were enrolled. Participants included mothers (100%) from Puerto Rico (75%), with a high-school diploma or higher (85%), with no written asthma action plan (65%), whose child's asthma diagnosis was present for at least 3 years (80%). Mean baseline asthma knowledge scores improved 8 points from 58.4 to 66.4 after watching the educational video (95% CI 5.3–10.7; t(19) = 6.21, p < 0.01). Knowledge improvements were similar across the ED and community groups. Knowledge gains were observed in the areas of ED utilization, medication usage, and activity limitations. Conclusions: The developed educational video improved caregiver asthma knowledge for a Latino population facing communication barriers to quality asthma care. Dissemination of this educational resource to LEP caregivers has the potential to improve pediatric asthma care in the United States.     

Child- and Caregiver-Reported Problems and Concerns in Using Asthma Medications

Objectives. The purpose of the study was to (a) describe the types of medication problems/concerns that asthmatic children and their caregivers reported and (b) examine the association between child and caregiver demographic and sociocultural characteristics and reported asthma medication problems/concerns. Methods. Children ages 8 through 16 with mild, moderate, or severe persistent asthma and their caregivers were recruited at five pediatric practices in nonurban areas of North Carolina. Children were interviewed and caregivers completed questionnaires after their child's medical visits about reported problems/concerns in using asthma medications. Multivariate logistic regression was used to analyze the data. Results. Three hundred and twenty children were recruited. Eighty-seven percent of the children reported a problem or concern in using their asthma medications. Approximately 40% of children reported side effects and a similar percent stated that it was hard to understand the directions on their medicines; in addition 60% reported that it was hard to remember when to take their medicines. Females and non-White children were significantly more likely to report they were not sure how to use an inhaler than males and White children. Younger and non-White children were significantly more likely to report it was hard to understand the directions on their medicines than older and White children. Caregivers were most likely to report that their children were bothered a little or a lot by side effects (31%) and a similar percent (29%) were not sure their children were using their inhalers properly. Caregivers without Medicaid were significantly more likely to report difficulty paying for the asthma medications. Conclusions. Medication side effects are a significant problem area for both children and their caregivers, and inhaler skill–based training is particularly needed for non-White children. Health care providers should discuss with children and their caregivers the types of problems/concerns that children may have when using their asthma medications.     

Findings from a community-based asthma education fair for Latino caregivers

Abstract

Objective: To assess limited English proficiency (LEP) asthma caregiver quality of life (QoL), skills retention and healthcare utilization after an asthma education fair (AEF). Methods: A language concordant AEF was conducted at a Latino community center. LEP caregivers of children 1–12 years old and an established asthma diagnosis participated in three skill stations: (a) medication recognition and administration, (b) peak flow use (if child?≥?5 years) and (c) action plan dissemination. Spacers, peak flow meters and individualized action plans were distributed. A validated, pediatric asthma caregiver quality of life questionnaire (PACQLQ-Spanish version) was administered. Baseline data was compared to follow-up interview data at three and six months after the AEF. Mean PACQLQ scores were analyzed with Wilcoxon signed-rank test and nominal paired data with McNemar’s test. Results: We analyzed data from 18 caregivers able to speak English well (22%), not well (28%) or not at all (50%). After three months, improved caregiver QoL was experienced (51 vs. 72, p?<?0.01). No differences were observed in medication recognition, spacer and peak flow use or peak flow interpretation. After six months, mean school days missed due to asthma decreased (4.1 vs. 0.4, p?<?0.01). Mean clinic visits, emergency department visits and hospitalizations remained unchanged. Conclusions: Implementation of a community-based AEF with action plan administration can be beneficial for LEP caregivers and their children. QoL improvements to emotional wellbeing and activity limitations were observed, and lower rates of school absenteeism were reported. Caregiver ability to accurately identify medications was not enhanced.     

The effect of parental social support and acculturation on childhood asthma control

Objective: There exists large ethnic disparities in asthma among Latino children; Puerto Ricans (PRs) are disproportionately affected, while Mexicans have the lowest prevalence and morbidity. Disparities are poorly understood, however, acculturation and social support are suggested to influence asthma control among children. This study investigated the relationship between acculturation, social support and asthma control among PR and Mexican children and their caregivers. Methods: Primary caregiver-child dyads (n?=?267) of PR (n?=?79) and Mexican (n?=?188) descent were recruited from clinics at two inner-city hospitals in Bronx, NY and three clinics in Phoenix, AZ. Children were 5–12 years of age and had a confirmed asthma diagnosis. Dyads completed measures of social support, acculturation and asthma control; logistic regression was used for analysis. Results: Mexican children had better asthma control than PR children (p?<?0.001). PR caregivers were more acculturated than Mexican caregivers (p?<?0.05); however, acculturation did not predict control. Across Latino subgroups caregivers’ total level of social support predicted better asthma control among children (p?<?0.05), and support received from family and friends each independently predicted better control (p?<?0.05). Conclusions: Results suggest that social support reduces some of the burden associated with asthma management enabling caretakers to better control their children’s asthma.     

Association of caregiver health beliefs and parenting stress with medication adherence in preschoolers with asthma

Objective: This study examined the associations of parenting stress and caregiver negative health beliefs with medication adherence in a sample of preschool-aged children with asthma.

Methods: Participants included 43 caregivers and their child with asthma, aged 2–5?years, who were prescribed a preventative or controller medication. Assessment included parent report of parenting stress associated with parental characteristics and difficult child behavior, health-related beliefs, and adherence to inhaled corticosteroids (ICS). Pharmacy refill records were reviewed to measure medication adherence objectively. Statistical analyses included paired samples t-test and Pearson’s correlation coefficients.

Results: Parent-report and objective measures of adherence to ICS were significantly different, with parents reporting significantly higher rates of medication adherence (p?p?Conclusions: Because the findings for parenting stress are not consistent with that of the literature on school-aged children with asthma, our results may suggest that preschool children are a unique developmental group. A review of endorsed health beliefs also highlights strengths and concerns for caregivers of these very young children. Overall, our study findings underscore the importance of caregivers’ health-related beliefs in promoting adherence to ICS in young children with asthma.