Culture-specific programs for children and adults from minority groups who have asthma

Study protocol of a prospective, interventional non-randomised trial investigating the impact of asthma education on specific disease understanding, health literacy and therapy outcome in childhood

INTRODUCTION

Childhood asthma is a highly prevalent chronic disease. A failure to implement patient education programmes may result in increased morbidity, despite the availability of distinct diagnostic and therapeutic approaches. Patients with lower socioeconomic status (SES) tend to have a higher asthma prevalence. Moreover, the progression of asthma is significantly influenced by factors such as health literacy and the children's specific knowledge about the condition. With this trial, the primary objective is to evaluate whether asthma education enhances specific disease understanding in children with asthma (primary outcome). Secondary objectives include evaluating training effects on health literacy, retention rates of information, 'Children Asthma Control Test' (C-ACT) score, frequency of emergency room and physician visits (secondary outcomes) and whether SES influences training effects.

METHODS AND ANALYSIS

To address the research objectives, this study comprises two projects. The first subproject will investigate the influence of asthma training on the development of disease understanding and health literacy. The second subproject will analyse the influence of SES on the outcome of children participating in asthma training. This research is designed as a comparative, non-randomised study involving two paediatric groups between the ages of ≥7 and < 14 years. After being diagnosed with asthma, the intervention group undergoes standardised psychoeducational asthma training at a certified centre associated with paediatricians in private practice in Germany, following the recommendations of the 'Arbeitsgruppe Asthmaschulung im Kindes- und Jugendalter e.V.', a national association aiming to establish uniform and guideline-based standards for patient education in children and adolescents. The comparison group receives a significantly shorter period of education and instruction on the usage of asthma medication at outpatient clinics. Data will be collected from patients and their parents at three specific survey time points, based on standardised tools.To describe mean differences between the intervention and control group over time (subproject 1), a repeated-measures analysis of variance (ANOVA) will be conducted. In subproject 2, multivariate linear regression analysis will be used to analyse the variables determining the changes in specific disease understanding and health literacy, including SES. The sample size calculation is based on a mixed ANOVA model with two groups and two measurements resulting in a total of 126 participants.

ETHICS AND DISSEMINATION

All protocols and a positive ethics approval were obtained from the Witten/Herdecke University, Germany (S-159, 2023; application submission: 24 June 2023, final vote: 10 July 2023). Furthermore, the study was registered at the German Clinical Trials Register (DRKS), DRKS00032423. The application submission was on 3 August 2023, and the final approval was on 4 August 2023. The results will be disseminated among experts and participants and will be published in peer-reviewed, international journal with open access.

TRIAL REGISTRATION NUMBER

DRKS00032423.

Impact of patient support programmes among patients with severe asthma treated with biological therapies: a systematic literature review and indirect treatment comparison

INTRODUCTION

Effective treatment of severe asthma requires patient adherence to inhaled and biological medications. Previous work has shown that patient support programmes (PSP) can improve adherence in patients with chronic diseases, but the impact of PSPs in patients with severe asthma treated with biologics has not been thoroughly investigated.

METHODS

We conducted a systematic literature review to understand the impact of PSPs on treatment adherence, asthma control and health-related quality of life (HRQoL) in patients with severe asthma. Embase, MEDLINE and EconLit databases were searched for studies published from 2003 (the year of the first biological approval for severe asthma) to June 2023 that described PSP participation among patients with severe asthma on biological treatment. Direct pooling of outcomes was not possible due to the heterogeneity across studies, so an indirect treatment comparison (ITC) was performed to determine the effect of PSP participation on treatment discontinuation. The ITC used patient-level data from patients treated with benralizumab either enrolled in a PSP (VOICE study, Connect 360 PSP) or not enrolled in a PSP (Benralizumab Patient Access Programme study) in the UK.

FINDINGS

25 records of 21 studies were selected. Six studies investigated the impact of PSPs on treatment adherence, asthma control or HRQoL. All six studies reported positive outcomes for patients enrolled in PSPs; the benefits of each PSP were closely linked to the services provided. The ITC showed that patients in the Connect 360 PSP group were less likely to discontinue treatment compared with the non-PSP group (OR 0.26, 95% CI 0.11 to 0.57, p<0.001).

CONCLUSIONS

PSPs contribute to positive clinical outcomes in patients with severe asthma on biological treatment. Future analyses will benefit from thorough descriptions of PSP services, and study designs that allow direct comparisons of patient outcomes with and without a PSP.

Effect of inspiratory muscle training in children with asthma: a systematic review and meta-analysis of randomized controlled trials

Background

Asthma is a common chronic respiratory disease in children. Alongside pharmacological interventions, inspiratory muscle training (IMT) emerges as a complementary therapeutic approach for asthma management. However, the extent of its efficacy in pediatric populations remains uncertain when compared to its benefits in adults. This systematic review aims to evaluate the effectiveness of IMT with threshold loading in children with asthma.

Methods

Randomized controlled trials (RCTs) evaluating the efficacy of inspiratory muscle training in pediatric asthma patients were identified through June 2023 across various literature databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAL), Web of Science, China Knowledge Resource Integrated Database (CNKI), Wei Pu Database, Wan Fang Database, and Chinese Biomedical Database (CBM). These trials compared inspiratory muscle training against sham inspiratory muscle training and conventional care. Eligible studies were assessed in terms of risk of bias and quality of evidence. Where feasible, data were pooled and subjected to meta-analysis, with results reported as mean differences (MDs) and 95% confidence intervals (CIs).

Results

Six trials involving 333 patients were included in the analysis. IMT demonstrated significant improvements in maximum inspiratory pressure (MIP) (MD 25.36, 95% CI 2.47-48.26, P = 0.03), maximum expiratory pressure (MEP) (MD 14.72, 95% CI 4.21-25.24, P = 0.006), forced vital capacity in percent predicted values [FVC(% pred)] (MD 3.90, 95% CI 1.86-5.93, P = 0.0002), forced expiratory volume in the first second in percent predicted values [FEV1(% pred)] (MD 4.96, 95% CI 2.60-7.32, P < 0.0001), ratio of forced expiratory volume in 1 s to forced vital capacity (FEV1/FVC) (MD 4.94, 95% CI 2.66-7.21, P < 0.0001), and asthma control test (ACT) (MD = 1.86, 95% CI: 0.96-2.75, P < 0.0001).

Conclusions

Findings from randomized controlled trials indicate that inspiratory muscle training enhances respiratory muscle strength and pulmonary function in pediatric asthma patients.

Systematic Review Registration

www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023449918, identifier: CRD42023449918.

Ethnic variation in asthma phenotypic presentation and outcomes: a cross-sectional analysis of the UK Biobank

Ethnic disparities exist within asthma; however, country of birth is rarely investigated. We described demographic and clinical characteristics by ethnicity and country of birth within the UK Biobank. Lung function and asthma hospitalisations were similar for white, black and North-East Asian participants, however, South-East (SE) Asians more commonly had an FEV1 below the lower limits of normal (LLN; 53.8% vs 32.3%, p<0.001), blood eosinophilia (38.6% vs 23.8%, p<0.001) and asthma hospitalisation (12.5% vs 8.3%, p<0.001) than white participants. First-generation SE Asian immigrants had poorer lung function (57.7% vs 27.7% FEV1 below LLN, p<0.001) than UK/Ireland born participants. These data demonstrate inter-ethnic and intra-ethnic disparities.

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Supporting the Respiratory Health of Migrants and Refugees

Migrants and refugees are at risk of developing acute and chronic respiratory diseases at their destination countries. Yet, people from these populations are also least likely to access care within the current health care system across the world. Although biological, psychological, and social factors play a role in influencing risk of respiratory diseases among these populations, the influences from cultural differences on health behaviors cannot be ignored. Cultural differences are influential in affecting an individual's level of health literacy. Health professionals can contribute to the provision of equitable care to diverse communities through addressing issues related to linguistic and cultural differences.

IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a cluster randomised controlled implementation trial

BACKGROUND

Asthma is a common long-term condition and major public health problem. Supported self-management for asthma that includes a written personalised asthma action plan, supported by regular professional review, reduces unscheduled consultations and improves asthma outcomes and quality of life. However, despite unequivocal inter/national guideline recommendations, supported self-management is poorly implemented in practice. The IMPlementing IMProved Asthma self-management as RouTine (IMP²ART) implementation strategy has been developed to address this challenge. The aim of this implementation trial is to determine whether facilitated delivery of the IMP²ART strategy increases the provision of asthma action plans and reduces unscheduled care in the context of routine UK primary care.

METHODS

IMP²ART is a parallel group, cluster randomised controlled hybrid II implementation trial. One hundred forty-four general practices will be randomly assigned to either the IMP²ART implementation strategy or control group. Following a facilitation workshop, implementation group practices will receive organisational resources to help them prioritise supported self-management (including audit and feedback; an IMP²ART asthma review template), training for professionals and resources to support patients to self-manage their asthma. The control group will continue with usual asthma care. The primary clinical outcome is the between-group difference in unscheduled care in the second year after randomisation (i.e. between 12 and 24 months post-randomisation) assessed from routine data. Additionally, a primary implementation outcome of asthma action plan ownership at 12 months will be assessed by questionnaire to a random sub-group of people with asthma. Secondary outcomes include the number of asthma reviews conducted, prescribing outcomes (reliever medication and oral steroids), asthma symptom control, patients' confidence in self-management and professional support and resource use. A health economic analysis will assess cost-effectiveness, and a mixed methods process evaluation will explore implementation, fidelity and adaptation.

DISCUSSION

The evidence for supported asthma self-management is overwhelming. This study will add to the literature regarding strategies that can effectively implement supported self-management in primary care to reduce unscheduled consultations and improve asthma outcomes and quality of life.

TRIAL REGISTRATION

ISRCTN15448074. Registered on 2 December 2019.

Efficacy and feasibility of the BREATHE asthma intervention with American Indian children: a randomized controlled trial

American Indian (AI) children experience significant disparities in asthma prevalence, severity, and burden of disease, yet few asthma education interventions are tested in this population. This study aimed to evaluate the efficacy and feasibility of the BREATHE intervention with parents and AI children, during a 3-year follow-up period (n = 108), using a randomized controlled design. Children with asthma identified by electronic medical records (EMR) were screened and matched with 2 controls. The intervention included an initial educational and 24 months of follow-up. The control group continued their usual care. The primary outcome was the frequency of EMR documented, emergency department (ED) visits or hospitalization for respiratory complaints. There was no statistical difference in mean primary outcomes (1.34 (1.98) vs 1.22 (1.95), - 0.88 to 0.63, 95% CI of the difference, p = 0.75), nor percent with any ED visit or hospitalization (29/53, 55% vs 30/55, 54%, p = 0.99) between the intervention or control groups respectively. After 365 days, there was a borderline significant difference in time to primary outcome. Although limited in power, the present study did not demonstrate a persistent effect of this intervention. We recommend that AI pediatric asthma interventions are culturally-designed, use feasible procedures, and repeat education at least every 12 months.

Redesigning culturally tailored intervention in the precision health era: Self-management science context

BACKGROUND

Nurse scientists have significantly contributed to health equity and ensuring cultural tailoring of interventions to meet unique needs of individuals. Methodologies for cultural tailoring of self-mangament interventions among marginalized populations have limitedly accommodated intersectionality and group heterogeneity when addressing health needs.

PURPOSE

Identify methodological limitations in cultural tailoring of interventions among priority populations and issue recommendations on cultural elements that researchers can target to ensure valid cultural tailoring approaches.

METHODS

Synthesis of literature on health equity, self-management, and implementation and dissemination research.

FINDINGS

Among priority populations, intersectionality and group heterogeneity has made group-based cultural tailoring approaches less effective in eliciting desirable health outcomes. Precision health methodology could be useful for cultural tailoring of interventions due to the methodology's focus on individual-level tailoring approaches.

DISCUSSION

We offer ways to advance health equity research using precision health approaches in cultural tailoring through targeting unique elements of culture and relevant psychosocial phenotypes.

Multi-lingual "Asthma APP" improves health knowledge of asthma among Australian First Nations carers of children with asthma

BACKGROUND

Among Australian First Nations people, asthma is associated with worse morbidity and mortality than non-First Nations people. Improving the delivery of health education that is innovative and culturally relevant to linguistically diverse populations is needed. Digital platforms, such as mobile applications (APP), have the potential to improve evidence-based health education, particularly in settings where access to specialist services is limited and turnover of staff is high, such as in remote Australia. In response to consumer needs, we developed a multi-lingual Asthma APP from our existing asthma flipchart, with a "voice-over" in seven local First Nations languages and English, using a mixture of static and interactive formats. In this study, we evaluated (a) the functionality and usability of the APP with First Nations health professionals with and without asthma and (b) whether the APP improves health knowledge and understanding of asthma among First Nations carers of children with asthma.

METHODS

In total, 7 First Nations health professionals participated in semi-structured interviews prior to the evaluation with 80 First Nations carers of children with asthma from the Northern Territory and Queensland, Australia. Carers underwent pre- and post-education questionnaires (maximum score = 25), where the post-questionnaire was administered immediately post the APP education session.

RESULTS

Health professionals found that APP was easy to navigate and culturally appropriate. Among the 80 carers, most were mothers (86%), aged between 26 and 50 years (75%) and 61% lived in remote settings (>100 km from a tertiary hospital). Most carers chose English audio (76%) with the remainder choosing one of the First Nations languages. Overall, asthma knowledge significantly improved post-education (median scores pre = 21 [interquartile range (IQR), 19-22; post = 24 (IQR 22-24), p = 0.05].

CONCLUSION

The First Nations-specific multi-lingual Asthma APP was easy to use and acceptable for the use by health professionals that also significantly improved short-term asthma knowledge among First Nations carers of children with asthma. The Asthma APP is an innovative and culturally acceptable method of delivering evidence-based, health education to culturally and linguistically diverse populations among Australian First Nations people.

Racial/ethnic differences in pediatric asthma management: the importance of asthma knowledge, symptom assessment, and family-provider collaboration

BACKGROUND

Asthma disproportionately impacts youth from marginalized minority backgrounds. Aspects of core asthma management (asthma management and medication beliefs) were examined among a cohort of diverse families.

METHODS

Caregiver-youth dyads (N = 92; Mage= 13.8 years; non-Hispanic/Latinx White (NLW) = 40%; Black/African-American = 25%; Hispanic/Latinx= 35%) completed a medication beliefs questionnaire (Medication Necessity, Medication Concerns) and a semi-structured interview (Family Asthma Management System Scale (FAMSS)). FAMSS subscales (Asthma Knowledge, Symptom Assessment, Family Response to Symptoms, Child Response to Symptoms, Environmental Control, Medication Adherence, Family-Provider Collaboration, and Balanced Integration) were used for analyses.

RESULTS

More Hispanic/Latinx families were at or below the poverty line (75%) relative to NLW (22%) and Black/African-American (39%) families (p < 0.001). Adherence (p < 0.01), Knowledge (p < 0.001), and Symptom Assessment (p < 0.01) were higher for NLW relative to Black/African-American families. Collaboration was higher among NLW (p = 0.01) and Hispanic/Latinx families (p = 0.05). Effect sizes were moderate (η2= 0.10-0.12). Parental race/ethnicity moderated the relationship between adherence and parental perceived medication concern and necessity for NLW and Hispanic/Latinx families. As medication concerns increased, medication adherence decreased, however, only for NLW and Hispanic/Latinx families.

CONCLUSIONS

In this sample, racial/ethnic differences emerged for elements of asthma management. Interview-based ratings of asthma management among Black/African-American families depicted lower asthma knowledge, lower levels of family-provider collaboration, and lower medication adherence. The relationship between medication concerns and adherence appeared to differ by ethnic group. Future research is needed to elucidate cultural factors that influence family-provider relationships and health-related behaviors, like medication use/adherence.

A Computer-Based Interactive Narrative and a Serious Game for Children With Asthma: Development and Content Validity Analysis

Background

Nonadherence to medications, failure to prevent exposure to asthma triggers, lack of knowledge about using medications, and fixed mindsets contribute to poor asthma control in children. Digital learning could provide a new strategy for improving health-related outcomes in children with asthma.

Objective

The aim of this study is to develop and design a digital educational program, titled Module of Inhaler and Asthma Triggers for Children (MIRACLE), for Indonesian children with asthma. The program comprises an interactive narrative and a serious game. It was proposed to increase the understanding of asthma self-management, instruct on proper inhaler techniques, improve asthma control, and promote a growth mindset for children with asthma.

Methods

Two phases of research were conducted to develop the program. In the first phase, a literature search and two rounds of the Delphi technique were conducted to obtain agreement from an expert panel regarding elements of asthma self-management and the design of interactive narratives and a serious game. The expert panel item statements were evaluated using the content validity index (CVI). In the second phase, the SERES framework, Norma Engaging Multimedia Design, and Psychological Theory of Growth Mindset were applied to create a storyline, learn objectives, and game challenges.

Results

In the first phase, 40 experts were invited to participate in Delphi round 1. Forty responses were collected to generate 38 item statements that consisted of part 1, elements of asthma self-management (25 items), and part 2, design of an interactive narrative and a serious game (13 items); 38 experts were involved in Delphi round 2. In total, 24 statements in part 1 and 13 items in part 2 had item-CVI values >0.80. The average CVI was 0.9, which was considered acceptable. Four narrative plots and five game sessions were developed during the second phase. Challenges with the scenario, scoring, and feedback on asthma difficulties were designed to promote a growth mindset for learners.

Conclusions

We developed a culture-specific, computer-based asthma program containing an interactive narrative and a serious game to deliver asthma self-management and promote a growth mindset among Indonesian children.

Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers

Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.

A structured collaborative approach to intervention design using a modified intervention mapping approach: a case study using the Management and Interventions for Asthma (MIA) project for South Asian children

BACKGROUND

To describe how using a combined approach of community-based participatory research and intervention mapping principles could inform the development of a tailored complex intervention to improve management of asthma for South Asian (SA) children; Management and Interventions for Asthma (MIA) study.

METHODS

A qualitative study using interviews, focus groups, workshops, and modified intervention mapping procedures to develop an intervention planning framework in an urban community setting in Leicester, UK. The modified form of intervention mapping (IM) included: systematic evidence synthesis; community study; families and healthcare professionals study; and development of potential collaborative intervention strategies. Participants in the community study were 63 SA community members and 12 key informants; in-depth semi-structured interviews involved 30 SA families, 14 White British (WB) families and 37 Healthcare Professionals (HCPs) treating SA children living with asthma; prioritisation workshops involved 145 SA, 6 WB and 37 HCP participants; 30 participants in finalisation workshops.

RESULTS

Two key principles were utilised throughout the development of the intervention; community-based participatory research (CBPR) principles and intervention mapping (IM) procedures. The CBPR approach allowed close engagement with stakeholders and generated valuable knowledge to inform intervention development. It accounted for diverse perceptions and experiences with regard to asthma and recognised the priorities of patients and their families/caregivers for service improvement. The 'ACT on Asthma' programme was devised, comprising four arms of an intervention strategy: education and training, clinical support, advice centre and raising awareness, to be co-ordinated by a central team.

CONCLUSIONS

The modified IM principles utilised in this study were systematic and informed by theory. The combined IM and participatory approach could be considered when tailoring interventions for other clinical problems within diverse communities. The IM approach to intervention development was however resource intensive. Working in meaningful collaboration with minority communities requires specific resources and a culturally competent methodology.

Culturally Appropriate Outreach Specialist Respiratory Medical Care Improves the Lung Function of Children in Regional and Remote Queensland

BACKGROUND AND OBJECTIVES

Indigenous Respiratory Outreach Care (IROC) is a culturally appropriate specialist respiratory service established to deliver multidisciplinary respiratory care to regional and remote Queensland communities. Our objective was to evaluate the impact of an outreach specialist respiratory service on the spirometry of children attending IROC clinics, particularly Indigenous children with asthma and bronchiectasis.

METHODS

Retrospective single-arm cohort study of 189 children who performed spirometry at twelve sites across regional and remote Queensland between October 2010 and December 2017. Each child's baseline spirometry was compared to their best spirometry at follow-up visit occurring within (1) 12 months of their most recent visit with at least 12 months of specialist care and; (2) each year of their first 3 years of care.

RESULTS

Forced expiratory volume in one second (FEV₁) and forced vital capacity (FVC) z-scores improved significantly across the whole group from baseline to follow-up (change in z-scores (Δz) of FEV₁ = 0.38, 95% CI 0.22, 0.53; ΔzFVC = 0.36, 95% CI 0.21, 0.51). In subgroup analyses, lung function significantly improved in Indigenous children (n = 141, ΔzFEV₁ = 0.37, 95% CI 0.17, 0.57; ΔzFVC = 0.36, 95% CI 0.17, 0.55) including those with asthma (n = 117, ΔzFEV₁ = 0.41, 95% CI 0.19, 0.64; ΔzFVC = 0.46, 95% CI 0.24, 0.68) and bronchiectasis (n = 38, ΔzFEV₁ = 0.33, 95% CI 0.07, 0.59; ΔzFVC = 0.26, 95% CI - 0.03, 0.53). Significant improvements in FEV₁ and FVC were observed within the first and second year of follow-up for Indigenous children, but not for non-Indigenous children.

CONCLUSION

The IROC model of care in regional and remote settings leads to significant lung function improvement in Indigenous children with asthma and bronchiectasis.

Regional Disparity in Asthma Prevalence and Distribution of Asthma Education Programs in Texas

Objectives

To identify the distribution of asthma education programs that are currently active in Texas and examine whether there is a geographical disparity between asthma prevalence and locations of asthma education programs in the Public Health Regions (PHRs) of Texas.

Methods

The data for adult asthma prevalence in PHRs was obtained from the Texas Department of State and Health Services (DSHS) 2015 Texas Behavioral Risk Factor Surveillance System (BRFSS) Public Use Data File. The Geographic Information System (GIS) program was used to show the distribution of asthma education programs and visually identify the isolated areas for asthma education programs on the maps. To examine the areas covered by the asthma education programs, we illustrated 50 miles and 70 miles of buffer zones from each program by proximity (multiple ring buffer) functions in GIS.

Results

We identified that 27 asthma education programs are active in Texas as of July 2019. The analysis showed that PHRs 1, 2, and 7 had the highest rate of asthma prevalence but had fewer asthma education programs. Also, the distribution of asthma education programs is concentrated around major cities, leading to a regional imbalance between asthma prevalence and locations of asthma education programs. The central and western areas of Texas proved to be marginalized areas for asthma education programs, particularly PHRs 2 and 9 because they may not be covered by the buffer zones of 70 miles from any asthma education programs. Discussion. This study revealed the marginalized regions in Texas lacking asthma education programs. The findings could help policymakers and health care professionals enhance opportunities to develop asthma education programs using different venues in isolated areas and prioritize these regions, for funds, to establish new asthma education programs.

Language and Latino immigrants living with spina bifida: Social determinants of health - the missing dimension in quality of life research

PURPOSE

Aware of the higher birth prevalence of spina bifida (SB) among Hispanics/Latinos, we aimed to appraise the literature as it relates to cultural context through a review of quality of life (QOL) studies conducted among individuals with SB in order to improve care among immigrant families.

METHODS

A systematic review was conducted consistent with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were: (1) children and adolescents (5-21 years of age) with SB and/or myelomeningocele; (2) quantitative studies; (3) health-related QOL outcome measured by validated instrument determinants; and (4) US-based studies. Articles meeting inclusion criteria were assessed using the focused conceptual framework informing the study (i.e., social determinants of health).

RESULTS

Eighteen studies met inclusion criteria, with eight different QOL instruments represented. The majority of studies used generic assessments of QOL (72%), two reported the use of both a generic and a SB-specific QOL measure (11%), and three (17%) documented QOL utilizing a SB-specific validated instrument. Only seven (39%) of the studies stated that they included Hispanics/Latinos and only six (33%) reported including Spanish-speaking individuals.

CONCLUSIONS

QOL in individuals with SB is mediated by a wide-range of interrelated factors. In order to better serve this vulnerable population as they transition across the lifespan, multilingual condition-specific QOL measures need to be further developed and implemented among Hispanic/Latino individuals with SB, especially those who are recent immigrants.

Filling the patient-provider knowledge gap: a patient advocate to address asthma care and self-management barriers

Introduction: In an ongoing study, a new clinical role adapted from a patient navigator called the patient advocate (PA) met with patients before medical visits, attended appointments and afterwards reviewed provider instructions. This qualitative analysis examines the perspectives of PAs and providers regarding their experiences with patients to understand how a PA can help patients and providers achieve better asthma control. Methods: PAs recorded journal entries about their experiences with patients. Provider focus groups and interviews were conducted by researchers and transcribed. Analysis was based on the Grounded Theory approach for qualitative research, using open and then focused coding. Two researchers independently coded these sources until intercoder agreement was achieved. Results: Upon review of 31 journal entries on PA experiences with 24 patients and transcripts from 2 provider focus groups and 12 provider interviews, 5 themes emerged surrounding asthma care and self-management: medication adherence, follow-up, communication, social determinants of health and time. While patients shared with PAs specific socioeconomic barriers to medication adherence and follow-up, providers often did not know about these problems and cited barriers to communication. Time restrictions on medical visits further limited communication. Conclusions: Perspectives reported here illustrate a gap in knowledge and understanding between patients and providers. The PA's unique relationship with patients and presence inside and outside of medical visits allowed them to learn contextual patient information unknown to providers. PAs and providers cited numerous ways PAs can help to improve patient-provider mutual understanding.

Patient-mediated interventions to improve professional practice

BACKGROUND

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

OBJECTIVES

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

SEARCH METHODS

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

SELECTION CRITERIA

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

MAIN RESULTS

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

AUTHORS' CONCLUSIONS

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

The Epidemiology of Chronic Suppurative Lung Disease and Bronchiectasis in Children and Adolescents

In the modern era, the global burden of childhood chronic suppurative lung disease (CSLD) remains poorly captured by the literature. What is clear, however, is that CSLD is essentially a disease of poverty. Disadvantaged children from indigenous and low- and middle-income populations had a substantially higher burden of CSLD, generally infectious in etiology and of a more severe nature, than children in high-income countries. A universal issue was the delay in diagnosis and the inconsistent reporting of clinical features. Importantly, infection-related CSLD is largely preventable. A considerable research and clinical effort is needed to identify modifiable risk factors and socioeconomic determinants of CSLD and provide robust evidence to guide optimal prevention and management strategies. The purpose of this review was to update the international literature on the epidemiology, etiology, and clinical features of pediatric CSLD.

Feasibility of a Peer-Led Asthma and Smoking Prevention Project in Australian Schools with High Indigenous Youth

BACKGROUND

The high global burden of asthma and tobacco smoking among Indigenous people may potentially be reduced by appropriate interventions that target prevention of tobacco smoke uptake and improved asthma management. The latter includes targeted treatment based on airway inflammation. We undertook a feasibility study in two Darwin schools with a high proportion of Indigenous youth to determine the feasibility of an innovative, peer-led, school-based education program called the Asthma and Smoking Prevention Project (ASPP). A subset of children with reported persistent respiratory symptoms were also clinically evaluated to determine the lower airway inflammatory profile and optimize asthma management.

METHODS

The ASPP is founded on an evidence-based three-step program and targets improving asthma management and preventing the uptake of tobacco smoking. The program uses a student-centered approach in which senior students (peer leaders) deliver the ASPP to Grade 7 students using activities, videos, and games. Students completed questionnaires related to asthma and smoking at baseline and 3 months after program delivery. Students with respiratory symptoms at 3 months were invited for a comprehensive clinical evaluation and tests including sputum induction.

RESULTS

The ASPP was well received. Of the 203 students involved, 56 (28%) were Indigenous and 70% completed baseline and follow-up questionnaires. Self-reported asthma was high (19%), 10% of students reported smoking and 63% reported exposure to tobacco at home. Of the 22 students who were clinically evaluated, 41% were Indigenous. Clinically important airway inflammation was high; 23% had Fractional Exhaled Nitric Oxide Levels ≥35 ppb, 88% had airway neutrophilia (>15%), and 29% had airway eosinophilia (>2.5%). Optimization of medication and management was required in 59% of students.

CONCLUSION

Our study has demonstrated the implementation of the ASPP was well received by the schools as well as by the students. The high prevalence of clinically important airway inflammation and suboptimal asthma management highlights the need for a community-based study on persistent respiratory symptoms in adolescents to reduce the burden of chronic lung disease particularly for Indigenous Australians.