Understanding pediatric inner-city asthma: an explanatory model approach

A higher Asthma Medication Ratio (AMR) predicts a decrease in ED visits among African American and Hispanic children

INTRODUCTION

Higher rates of ED visits and hospitalizations for asthma among African American and Hispanic children may indicate suboptimal management of asthma, leading to a greater financial burden of healthcare. It is not well known if an association of race/ethnicity with controller medication and hospital-based care utilization exists.

OBJECTIVE

This study examines whether the Asthma Medication Ratio (AMR) predicts healthcare utilization for asthma by race/ethnicity.

METHODS

4,584 Medi-Cal children (Ages 5-11) with persistent asthma in Los Angeles were identified and their AMRs (2018) were calculated based on the HEDIS criteria. Healthcare utilization data were used, including hospitalizations, ED visits, and pharmacy claims to examine whether a higher AMR predicts decreases in healthcare utilization by race/ethnicity in the subsequent 3,6, and 12 months (2019).

RESULTS

The average AMR was lowest among African American children (0.401). In the subsequent 12 months, they were highest in ED visits (0.249) and hospitalizations (0.121), but lowest in outpatient visits (0.793). The results of logistic regression showed that a higher value of AMR (>0.5) contributed to decreases in ED visits in the subsequent 12 months only among African Americans (OR = 0.551, 95% CI 0.364-0.832) and Hispanics (OR = 0.613, 95% CI 0.489-0.770). No association between AMR and hospitalizations was found.

CONCLUSIONS

Our findings indicate that increased use of controller medication contributes to a decrease in ED visits among African American and Hispanic children with persistent asthma. Increased use of controller medications and caregiver's efforts for medication adherence may contribute to a reduction in asthma disparities.

How do embodied experiences of asthma influence caregiver conceptual models?

RATIONALE

Many studies propose that patients', caregivers', and children's asthma management practices may diverge from biomedical recommendations because their understandings of asthma (i.e., conceptual models) are different from biomedical perspectives. However, little research in this area has examined conceptual models of asthma using embodiment theory, which suggests that caregivers' and children's experiences of the physical body shape their perspectives and consequent management strategies.

OBJECTIVE

We investigated how two embodied processes of symptom perception-detection and interpretation-may influence caregiver or patient conceptions of asthma.

METHODS

We interviewed 41 caregivers of children with asthma in Gainesville, Florida, and St. Louis, Missouri, and conducted ethnographic visits or virtual interviews with 19 children with asthma aged 6-16.

RESULTS

Four aspects of asthma's embodied experience shaped conceptual models via processes of detection and interpretation: 1) symptoms are experienced in the context of other bodily processes; 2) acute symptoms and exacerbations are more salient than their absence; 3) the embodied experience of asthma is one of integrated physiological and emotional processes; and 4) caregivers and children acquire embodied practices of perceiving symptoms that produce embodied knowledge.

CONCLUSION

Participant narratives suggest that embodied experiences of asthma shape caregivers' and children's understandings of asthma in ways that differ from the biomedical model. We argue that a focus on embodied experiences may provide important ground for mutual understanding and communication between providers and caregivers and/or patients.

Parents' self-reported experiences and information needs related to acute pediatric asthma exacerbations: A mixed studies systematic review

Objective

To systematically review the scientific literature examining parents' experiences and information needs for the management of their child's asthma exacerbations.

Methods

We searched five databases for quantitative and qualitative studies in Canada and the United States from 2002 onwards. A convergent integrated approach and the Mixed Method Appraisal Tool were used to analyze and appraise the evidence, respectively.

Results

We included 84 studies (27 quantitative, 54 qualitative, 3 mixed methods). Some parents lacked confidence in recognizing or managing exacerbations. A few parents were uncertain when and where to seek medical help. The main barrier to accessing care was cost. Impacts on parents included poor sleep, distress, and lifestyle disruptions. Parents felt they lacked information and wanted education on treatments and how to recognize and manage exacerbations via education sessions, written materials, community outreach and online resources.

Conclusion

Improved education for parents may help reduce parents' stress, asthma-related morbidities for children and use of urgent health services.

Innovation

The development of tailored interventions and knowledge translation strategies with input from target audiences (e.g. parents, health care providers) is necessary to meet their information needs and support adherence to clinical recommendations.

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84 studies reviewed and analyzed using the convergent integrated approach

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Parents lacked confidence in recognizing, treating or seeking care for exacerbations

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Cost was a barrier to care; parents affected by psychosocial impacts

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Parent's desired education on treatments and how to recognize and manage exacerbations

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Interventions and knowledge translation strategies must be developed with parents

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.

Medication adherence in pediatric asthma: A systematic review of the literature

OBJECTIVE

To provide a systematic review of correlates of adherence to inhaled corticosteroids (ICS) in pediatric asthma across the individual, family, community, and healthcare system domains.

METHODS

Articles assessing medication adherence in pediatric asthma published from 1997 to 2016 were identified using PsychINFO, Medline, and CINAHL. Search terms included asthma, compliance, self-management, adherence, child, and youth. Search results were limited to articles: 1) published in the US; 2) using a pediatric population (0-25 years old); and 3) presenting original data related to ICS adherence. Correlates of adherence were categorized according to the domains of the Pediatric Self-Management Model. Each article was evaluated for study quality.

RESULTS

Seventy-nine articles were included in the review. Family-level correlates were most commonly reported (N = 51) and included socioeconomic status, race/ethnicity, health behaviors, and asthma knowledge. Individual-level correlates were second-most common (N = 37), with age being the most frequently identified negative correlate of adherence. Health care system correlates (N = 24) included enhanced asthma care and patient-provider communication. Few studies (N = 10) examined community correlates of adherence. Overall study quality was moderate, with few quantitative articles (26.38%) and qualitative articles (21.4%) referencing a theoretical basis for their studies.

CONCLUSIONS

All Pediatric Self-Management Model domains were correlated with youth adherence, which suggests medication adherence is influenced across multiple systems; however, most studies assessed adherence correlates within a single domain. Future research is needed that cuts across multiple domains to advance understanding of determinants of adherence.

Beliefs Regarding Asthma Management Relating to Asthma Action Plans (AAPs) of African American Caregivers Residing in Newark, New Jersey Public Housing Communities

PURPOSE

The purpose of this study was to explore the beliefs regarding asthma management and Asthma Action Plans (AAPs) of African American caregivers residing in three New Jersey public housing communities in Newark, New Jersey.

DESIGN

A qualitative methods design was accomplished using semi-structured interviews with a purposive sample of nine African American caregivers of children with asthma. Information was coded using N'VIVO™; the textual analysis combined codes into categories, which were then assembled into themes.

RESULTS

Self-determination was found to be a fundamental goal of asthma management; however, three themes emerged as barriers and facilitators to this goal: challenges in the urban environment, preference of familial methods, and access to medical care.

CONCLUSIONS

Findings from this study regarding minority caregivers' beliefs regarding difficulty navigating the health care system coupled with insurance instability, leading to use of Emergency Departments, are consistent with past research. Although caregivers expressed belief in use of prescribed medications as indicated on AAPs, familial methods, found to provide a sense of control over asthma, were preferred.

Acculturation and quality of life in urban, African American caregivers of children with asthma

OBJECTIVE

Racial/ethnic minority caregivers of children with asthma are at risk for low levels of quality of life (QOL). Limited research has identified factors that contribute to lower QOL among African American caregivers. This study examined associations between acculturation (e.g., engaging in values/beliefs traditional of one's culture versus adopting mainstream cultural views) and caregiver QOL in low-income, urban African American families of children (7-12 years) with persistent asthma. We also investigated the association between caregiver QOL and child emergency department (ED) use.

METHODS

Fifty-five caregivers and their children completed interview-based questionnaires in a single research session. Caregivers completed the Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ), the African American Acculturation Scale-Revised (AAAS-R), and reported on child asthma variables. Children completed items assessing asthma control.

RESULTS

Higher overall QOL and emotional function subscale scores were associated with more traditional African American religious beliefs/practices (r = .288, p = .033; r = .333, p = .013). Higher emotional function subscale scores were associated with more traditional values of African American families (r = .306, p = .023). Lower QOL was found among caregivers of children who had visited the ED three or more times in the last year.

CONCLUSIONS

Less acculturation tied to religious beliefs/practices and family values (as measured by the AAAS-R) may serve a protective role in reducing the burden low-income, urban African American caregivers experience in managing child asthma. This study is the first of its kind to study acculturation in African American caregivers of children with asthma.

Changes in clinical conversations when providers are informed of asthma patients' beliefs about medication use and integrative medical therapies

OBJECTIVES

To explore whether patient's personal beliefs about inhaled corticosteroid (ICS) and integrative medicine (IM) are discussed at routine primary care visits for asthma.

BACKGROUND

Negative medication beliefs and preferences for IM can be salient barriers to effective asthma self-management.

METHOD

A qualitative analysis of transcripts from 33 audio-recorded primary care visits using conventional content analysis techniques.

RESULTS

Four themes emerged when providers had knowledge of patient's beliefs: negative ICS beliefs, IM use for asthma, decision-making and healthy lifestyles. Two themes were identified when providers did not have this knowledge: asthma self-management and healthy lifestyles.

CONCLUSION

When providers had knowledge of their patient's IM endorsement or negative ICS beliefs, they initiated conversations about these modifiable beliefs. Without training in IM and in effective communication techniques, it is unlikely that providers will be able to effectively engage in shared decision-making aimed at improving asthma self-management.

Domestic experiments: familial regimes of coping with childhood asthma in New Zealand

In this article, I examine the self-positioning of many New Zealand mothers of children with asthma as parent-experts whose authority supersedes that of implementing the self-management strategies advocated by medical professionals. In a socio-political context that emphasizes neoliberal values of autonomy and self-responsibility, these parent-experts experiment with a variety of pharmaceutical regimes, determining familial modes of care that privilege the achievement of what they consider to be 'normal childhoods.' While some families accept asthma as a chronic condition and encourage children to adopt standardized, daily preventative regimes, others craft alternative strategies of pharmaceutical use that allow them to experientially maintain asthma as a sporadic and temporary, if frequent and sometimes dramatic, interruption of everyday life. Childhood asthma care practices are thus not only vested in kinship networks, but often arise out of familial-based experiments whose goal is to determine regimes that enable the preservation of 'normality.'

The use of a collaborative structured methodology for the development of a multifaceted intervention programme for the management of asthma (the MIA project), tailored to the needs of children and families of South Asian origin: a community-based, participatory study

Background

Asthma is one of the most common chronic childhood illnesses in the UK. South Asian children are more likely to suffer from their asthma and be admitted to hospital. While this inequality needs to be addressed, standard behaviour-change interventions are known to be less successful in minority ethnic groups. Evidence suggests a need to enhance services provided to ethnic minority communities by developing culturally sensitive tailored interventions.

Objectives

The Management and Interventions for Asthma (MIA) project aimed to test an iterative multiphase participatory approach to intervention development underpinned by the socioecological model of health, producing an intervention-planning framework and enhancing an evidence-based understanding of asthma management in South Asian and White British children.

Design

Interviews and focus groups facilitated by community facilitators (CFs) were used to explore knowledge and perceptions of asthma among South Asian communities, children, families and healthcare professionals (HCPs). A smaller comparison group of White British families was recruited to identify aspects of asthma management that could be addressed either by generic interventions or by a tailored approach. Collaborative workshops were held to develop an intervention planning framework and to prioritise an aspect of asthma management that would be used as an exemplar for the development of the tailored, multifaceted asthma intervention programme.

Setting

The community study was based in a largely urban environment in Leicester, UK.

Participants

Participants were recruited directly from the South Asian (Indian, Pakistani and Bangladeshi) and White British communities, and through the NHS. Children were aged between 4 and 12 years, with a range of asthma severity.

Intervention development

The study had four phases. Phase 1 consisted of an evidence review of barriers and facilitators to asthma management in South Asian children. Phase 2 explored lay understandings of childhood asthma and its management among South Asian community members (n = 63). Phase 3 explored perceptions and experiences of asthma management among South Asian (n = 82) and White British families (n = 31) and HCP perspectives (n = 37). Using a modified intervention mapping approach incorporating psychological theory, phase 4 developed an intervention planning framework addressing the whole asthma pathway leading to the development of an exemplar multifaceted, integrated intervention programme called ‘ACT [Awareness, Context (cultural and organisational) and Training] on Asthma’.

Results

Data on the social patterning of perceptions of asthma and a lack of alignment between the organisation of health services, and the priorities and competencies of British South Asian communities and families were produced. Eleven key problem areas along the asthma pathway were identified. A four-arm multifaceted tailored programme, ‘ACT on Asthma’, was developed, focusing on the theme ‘getting a diagnosis’. This theme was chosen following prioritisation by families during the collaborative workshops, demonstrating the participatory, iterative, phased approach used for the intervention design.

Conclusions

The MIA study demonstrated barriers to optimal asthma management in children at the family, provider and healthcare system levels and across the whole asthma pathway. Interventions need to address each of these levels to be effective. Minority ethnic communities can be successfully engaged in collaborative intervention development with a community-focused and culturally sensitive methodology.

Future work

Further research is required to (1) assess the feasibility and effectiveness of the proposed ‘ACT on Asthma’ programme, (2) develop methods to increase active participation of children in research and service development, (3) develop and test strategies to enhance public understanding of asthma in South Asian communities and (4) identify effective means of engaging the wider family in optimising asthma management.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Medication use in Indian children with asthma: the user's perspective

BACKGROUND AND OBJECTIVE

Despite the high prevalence of asthma in children, there has been limited research into patient perception of medication use, particularly in the developing world. This study therefore aimed to carry out an in-depth exploration of the views of carers and children with asthma on asthma medication use.

METHODS

Grounded theory approach was used to conduct semistructured qualitative interviews in a purposive convenience sample of parents and children with asthma. The participants were recruited from two specialty hospitals in New Delhi, India. Interviews were tape-recorded, transcribed verbatim and thematically analysed.

RESULTS

Twenty children (7-12 years old) with asthma and their parent or carer were interviewed in July 2011. Major reported issues included poor parent and child understanding of disease and medications. Fears, misinformed beliefs and lack of self-management skills were apparent. Child self-image, resistance to medication use and lack of responsibility in medication taking were themes that emerged from child interviews.

CONCLUSIONS

This is one of the first research studies exploring the viewpoint of children with asthma about their medications. Resource constraints dictate a pragmatic paternalistic approach by physicians which, in contrast to patients in westernized nations, seems to be acceptable and satisfactory to Indian patients (carers).

A systematic review of complementary and alternative medicine for asthma self-management

This article is a systematic review of complementary and alternative medicine use for pediatric and adult asthma self-management. The aim of the review was to summarize the existing body of research regarding the types and patterns of, adverse events and risky behaviors associated with, and patient-provider communication about complementary therapies in asthma. This evidence serves as the basis for a series of recommendations in support of patient-centered care, which addresses both patient preferences for integrated treatment and patient safety.

Medication use in Australian children with asthma: user's perspective

BACKGROUND AND OBJECTIVES

Medication use-related issues remain problematic in childhood asthma despite effective treatment strategies and public investment into improved asthma management strategies in industrialized countries. This study aimed to carry out an in-depth exploration of the views of parents/carers and children with asthma on medication use.

METHODS

Semi-structured qualitative interviews were conducted with a purposive convenience sample of children with asthma and their parents recruited from general practices in Sydney. Interviews were tape-recorded, transcribed verbatim, and thematically analyzed.

RESULTS

A total of 52 interviews (26 parents/carers and 26 children with asthma) were conducted. Major themes which emerged from the children's interviews included issues such as self-image, resistance to medication use, and lack of responsibility in medication taking. Parental or carer issues included lack of clear understanding of how medications worked, as well as administration difficulties, cost constraints, and beliefs about medications contrary to quality use.

DISCUSSION

This is one of the few research studies exploring the viewpoint of children with asthma about their medications in Australia. Despite investment in dissemination of professional, targeted evidence-based asthma management strategies in healthcare, there seems to be a lack of depth in terms of what parents understand about their child's asthma. Effective communication about medication usage, especially the inclusion of the child in the consultation to empower them to be involved in their own asthma care, may be the answer.

Health beliefs, treatment preferences and complementary and alternative medicine for asthma, smoking and lung cancer self-management in diverse Black communities

OBJECTIVE

The purpose of this literature review is to characterize unconventional health beliefs and complementary and alternative medicine (CAM) for asthma, smoking and lung cancer as those that are likely safe and those that likely increase risk in diverse Black communities. These findings should provide the impetus for enhanced patient-provider communication that elicits patients' beliefs and self-management preferences so that they may be accommodated, or when necessary, reconciled through discussion and partnership.

METHODS

Original research articles relevant to this topic were obtained by conducting a literature search of the PubMed Plus, PsychINFO and SCOPUS databases using combinations of the following search terms: asthma, lung cancer, emphysema, chronic obstructive pulmonary disease (COPD), smoking, beliefs, complementary medicine, alternative medicine, complementary and alternative medicine (CAM), explanatory models, African American, and Black.

RESULTS

Using predetermined inclusion and exclusion criteria, 51 original research papers were retained. Taken together, they provide evidence that patients hold unconventional beliefs about the origins of asthma and lung cancer and the health risks of smoking, have negative opinions of standard medical and surgical treatments, and have favorable attitudes about using CAM. All but a small number of CAM and health behaviors were considered safe.

CONCLUSION

When patients' unconventional beliefs and preferences are not identified and discussed, there is an increased risk that standard approaches to self-management of lung disease will be sub-optimal, that potentially dangerous CAM practices might be used and that timely medical interventions may be delayed.

PRACTICE IMPLICATIONS

Providers need effective communication skills as the medical dialog forms the basis of patients' understanding of disease and self-management options. The preferred endpoint of such discussions should be agreement around an integrated treatment plan that is effective, safe and acceptable to both.

Puerto Rican families' experiences of asthma and use of the emergency department for asthma care

Puerto Ricans have been found to have higher asthma prevalence rates than non-Hispanic whites, blacks, and all other Hispanic subgroups. They also have the highest rates of emergency department (ED) use for the management of their asthma. Using a hermeneutic phenomenological approach, the aim of this study was to describe the lived experience of Puerto Rican families caring for their child's asthma and using the ED for asthma care. Six themes were generated from in-depth interviews with 10 Puerto-Rican caregivers: (1) The Folklore of Asthma, (2) Culture and the Medicine Woman, (3) In Awe of Asthma, (4) Praying to God, (5) The Decision-Time to Go, and (6) The ED Environment. The findings emphasize the necessity of establishing and maintaining a therapeutic partnership between primary care providers and families of children with asthma. The results may be used as a foundation for understanding motivations for seeking asthma care in the ED.

Caregiver expectations of clinicians during the asthma diagnostic process in young children: thematic analysis of focus groups

OBJECTIVE

Asthma is difficult to diagnose in young children, and the subjective experience of caregivers varies. Clinicians' ability to meet caregiver expectations during the diagnostic process improves the caregiver-clinician relationship, and effectiveness of disease management strategies.

METHODS

We performed thematic analysis of seven focus groups (FGs) with 38 caregivers of children 1-6 years old diagnosed with asthma in the preceding 12 months. Caregivers were classified as satisfied or dissatisfied with clinicians during the asthma diagnostic process. Differential themes in these two groups identified caregiver expectations that determined satisfaction with the diagnostic process.

RESULTS

Caregiver expectations during the asthma diagnostic process included (1) provision of a diagnostic strategy, (2) acknowledgment of caregiver advocacy, (3) addressing caregiver's beliefs about treatment with asthma medications before a diagnosis was confirmed, and (4) discussing asthma specialist involvement in the diagnosis. Higher perceived severity of a child's illness made caregiver expectations more difficult to meet.

CONCLUSIONS

We conclude that clinicians considering an asthma diagnosis in young children must include a diagnostic strategy that is congruent with the caregiver's beliefs about the underlying illness, use of medication, and asthma specialist involvement. Perceived illness severity must also be accounted for when designing a diagnostic strategy.

Complementary and alternative medicine use and adherence with pediatric asthma treatment

BACKGROUND AND OBJECTIVE

Complementary and alternative medicine (CAM) use for pediatric asthma is increasing. The authors of previous studies linked CAM use with decreased adherence to conventional asthma medicines; however, these studies were limited by cross-sectional design. Our objective was to assess the effect of starting CAM on pediatric adherence with daily asthma medications.

METHODS

We used a retrospective cohort study design. Telephone surveys were administered to caregivers of patients with asthma annually from 2004 to 2007. Dependent variables were percent missed doses per week and a previously validated "Medication Adherence Scale score." Independent variables included demographic factors, caregiver perception of asthma control, and initiation of CAM for asthma. We used multivariate linear regression to assess the relationship between medication adherence and previous initiation of CAM.

RESULTS

From our longitudinal data set of 1322 patients, we focused on 187 children prescribed daily medications for all 3 years of our study. Patients had high rates of adherence. The mean percent missed asthma daily controller medication doses per week was 7.7% (SD = 14.2%). Medication Adherence Scale scores (range: 4-20, with lower scores reflecting higher adherence) had an overall mean of 7.5 (SD = 2.9). In multivariate analyses, controlling for demographic factors and asthma severity, initiation of CAM use was not associated with subsequent adherence (P > .05).

CONCLUSIONS

The data from this study suggest that CAM use is not necessarily "competitive" with conventional asthma therapies; families may incorporate different health belief systems simultaneously in their asthma management. As CAM use becomes more prevalent, it is important for physicians to ask about CAM use in a nonjudgmental fashion.

Parental preferences for FDA-approved medications prescribed for their children

OBJECTIVE

To describe parental preferences for FDA-approved prescription medications for their children.

STUDY DESIGN

Cross-sectional Web-enabled survey of a national sample of 1562 parents.

RESULTS

Response rate was 61%. Most parents (77%) preferred prescription of only FDA-approved medications for their child. However, one half of parents preferred that their child's doctor prescribe medication that is safest and works best, even if not FDA approved for children. One third of parents (34%) preferred nothing but FDA-approved medications for their child, regardless of drug safety, effectiveness, or cost. Controlling for parent race and education, mothers (odds ratio = 1.52; P = .004) and older parents (odds ratio = 1.60; P = .025) were more likely to prefer nothing but FDA-approved medications for their children compared with fathers and younger parents.

CONCLUSIONS

Although most parents initially indicate preference for FDA-approved medications, one half of parents will accept a non-FDA-approved medication for their children with the understanding that it is safer or more effective than the FDA-approved alternative.

Knowledge and use of ethnomedical treatments for asthma among Puerto Ricans in an urban community

PURPOSE

Puerto Ricans have higher lifetime and current asthma prevalence than other racial and ethnic groups in the United States. A great many Hispanics use ethnomedical therapies for asthma. This study elicited participant knowledge of ethnomedical therapies, developed a typology of the therapies, and considered whether some types are used or deemed efficacious based, in part, on information source.

METHODS

Eligible participants were randomly selected from the medical records of an inner-city primary care clinic serving a predominantly Hispanic community in Buffalo, New York. Thirty adult Puerto Ricans who had asthma or were care-givers of children with asthma were interviewed in person using a semistructured instrument. Qualitative data analysis followed a content-driven immersion-crystallization approach. Outcome measures were ethnomedical treatments for asthma known to participants, whether these treatments were used or perceived effective, and the participant's information source about the treatment.

RESULTS

Participants identified 75 ethnomedical treatments for asthma. Behavioral strategies were significantly more likely to be used or perceived effective compared with ingested and topical remedies (P <.001). Among information sources for ingested and topical remedies, those recommended by community members were significantly less likely to be used or perceived effective (P <.001) compared with other sources.

CONCLUSIONS

This sample of Puerto Ricans with a regular source of medical care was significantly more likely to use or perceive as effective behavioral strategies compared with ingested and topical remedies. Allopathic clinicians should ask Puerto Rican patients about their use of ethnomedical therapies for asthma to better understand their health beliefs and to integrate ethnomedical therapies with allopathic medicine.

Illustrating risk: anaphylaxis through the eyes of the food-allergic child

The risk perception research is widely focused on children as targets of risk. To date, very few studies have consulted with the impacted group to assess the perceptions of risk associated with the exposures of interest. Much less research has investigated the experiences of children at risk for anaphylaxis, their concerns, and the psychosocial stresses associated with risk. The present study explores the perceptions and experiences of Ontario students with anaphylaxis, and their parents regarding school as a safe place in order to inform school policy around risk management and coping. A "child-centered" analytical framework incorporating illustrative techniques within interpretative analysis is outlined. Five prominent themes: (a) social and environmental barriers to safety, (b) coping strategies, (c) emotional burden of responsibility, (d) balance of responsibility (transitions), and (e) redefining "normal" are discussed. Results found that "child-centered" techniques empowered children in a process that is meaningful and relevant to their lives. A preliminary framework for understanding what risk means to children highlighted the differences in how they cope in the public sphere of school.

Ecological barriers and social forces in childhood asthma management: examining routines of African American families living in the inner city

OBJECTIVE

Asthma affects African American children at unprecedented rates. Researchers have examined the context in which African American families live and experience illness, and suggest that ecological barriers contribute to poor health. In this paper, the authors examine the social forces underlying these ecological barriers and what African American parents living in the inner city do to manage their children's asthma amidst these challenges.

METHODS

African American parents of children aged 5 to 12 years diagnosed with persistent asthma living in the inner city were interviewed using a semistructured interview guide. Grounded theory analysis identified recurrent themes in the interview data.

FINDINGS

Parents identified four adaptive routines they use to manage their children's asthma: ( 1 ) give young children with asthma responsibility for medication use; ( 2 ) monitor the availability of the school nurse; ( 3 ) manage air quality; and ( 4 ) frequently clean the home. These routines are described as adaptive because parents navigate ecological barriers and social forces within their daily context to manage their children's asthma.

IMPLICATIONS

The authors argue that the first step in reducing the impact of ecological barriers is understanding African Americans' sociohistorical context.

Explanatory models of asthma in the southeast asian community

PURPOSE

To examine how two groups (parents and healthcare providers) perceive asthma in Southeast (SE) Asian children in the United States, and to address issues of access to asthma care.

STUDY DESIGN AND METHODS

Using Kleinman's Explanatory Models (EM) approach, semistructured interviews were used with 12 families and 26 providers. Families were interviewed in a clinic setting. Providers read a case example of a SE Asian child with asthma and were asked to anticipate the case family's EM of asthma. Data were analyzed using template analytic technique in which segments were clustered into etiology, causation, treatments, asthma impact, and access to asthma care.

RESULTS

Families predominately followed current asthma practice guidelines, whereas providers believed that SE Asian families primarily followed cultural practices. Families described the severity and impact of asthma as more intense than the providers described the same items. While families identified barriers to care as difficulty getting appointments and unavailable providers, providers viewed family barriers to be predominately culturally based. Both groups noted the need for education and frequent healthcare visits as facilitators to care.

CLINICAL IMPLICATIONS

This study suggests that important differences may exist between the way providers and SE Asian families perceive childhood asthma. Nurses are encouraged to ask the families in their care how they explain their children's asthma, thus facilitating more culturally competent care and increased ability to meet the family's needs. Implications for policy change relative to improving access to care to immigrant groups are also suggested.

What affects asthma medicine use in children? Australian asthma educator perspectives

The global burden of childhood asthma is significant. Health care systems are faced with increasing financial costs, while children with asthma and their caretakers are faced with poorer physical health, emotional health, and quality of life. Despite the availability of effective treatment, the quality use of asthma medicines in children remains suboptimal. An investigation was conducted to explore issues related to children's asthma medicine usage from the perspective of the health care professional. Although current literature has elicited the views of caretakers and children, the health care professional viewpoint has been relatively unexplored. Semi-structured qualitative interviews were conducted with a convenience sample of 21 Australian asthma educators. Interviews were audiotaped and transcribed, and transcripts were thematically analyzed with the assistance of NVivo 7. Emergent themes associated with health care professionals, parents, medicines, children, and educational resources were found. Major issues included a lack of information provided to parents, poor parental understanding of medicines, the high cost of medicines and devices, child self-image, the need for more child responsibility over asthma management, and the lack of standardization, access to, and funding for educational resources on childhood asthma. There are multitudes of key issues that may affect asthma medicines usage in children. This research will help inform the development of educational tools on the use of medicines in childhood asthma that can be evaluated for their effectiveness in getting key messages to target audiences such as children, caretakers, and teachers.

Asthma beliefs among mothers and children from different ethnic origins living in Amsterdam, the Netherlands

Background

Doctors and patients hold varying beliefs concerning illness and treatment. Patients' and families' explanatory models (EMs) vary according to personality and sociocultural factors. In a multi-ethnic society, it is becoming increasingly significant that doctors understand the different beliefs of their patients in order to improve patient/doctor communication as well as patient adherence to treatment.

Methods

Twelve focus groups were formed, consisting of 40 children diagnosed with asthma, as well as 28 mothers of these children. These groups included mothers and children of different ethnicities who were living in Amsterdam, the Netherlands. In order to understand the beliefs that both mothers and children hold regarding asthma and its treatment, the explanatory models were analysed and compared.

Results

Study findings show that mothers and children, regardless of ethnicity and age, have their own EMs. Overall, there is a great deal of uncertainty related to the causes, consequences, problems, and symptoms of asthma and its treatment. It also seems that many concerns and feelings of discomfort are the result of lack of knowledge. For instance, the fact that asthma is not seen as a chronic disease requiring daily intake of an inhaled corticosteroid, but rather as an acute phenomenon triggered by various factors, may be very relevant for clinical practice. This particular belief might suggest an explanation for non-adherent behaviour.

Conclusion

A thorough understanding of the mothers' and children's beliefs regarding the illness and its treatment is an important aspect in the management of asthma. Gaining an understanding of these beliefs will provide a foundation for a solid clinician-patient/family partnership in asthma care. Although ethnic differences were observed, the similarities between the mothers' and children's beliefs in this multi-ethnic population were striking. In particular, a common belief is that asthma is considered an acute rather than a chronic condition. In addition, there is a lack of knowledge about the course and the self-management of asthma. Health care providers should be aware of these commonly held beliefs, and this information could be shared in educational programs.

Factors that influence quality of life in rural children with asthma and their parents

INTRODUCTION

Among rural children with asthma and their parents, this study examined the relationship between parental and child reports of quality of life and described the relationship of several factors such as asthma severity, missed days of work, and asthma education on their quality of life.

METHODS

Two hundred one rural families with asthma were enrolled in a school-based educational program. Intervention parents and children participated in interactive asthma workshop(s) and received asthma devices and literature. Parent and child quality of life measurements were obtained before and after the intervention using Juniper's Paediatric Caregivers Quality of Life and Juniper's Paediatric Quality of Life Questionnaires. Asthma severity was measured using criteria from the National Asthma Education and Prevention Program guidelines.

RESULTS

There was no association between parent and child total quality of life scores, and mean parental total quality of life scores were higher at baseline and follow-up than those of the children. All the parents' quality of life scores were correlated with parental reports of missed days of work. For all children, emotional quality of life (EQOL) was significantly associated with parental reports of school days missed (P = .03) and marginally associated with parental reports of hospitalizations due to asthma (P = .08). Parent's EQOL and activity quality of life (AQOL) were significantly associated with children's asthma severity (EQOL, P = .009; AQOL, P = .03), but not the asthma educational intervention. None of the child quality of life measurements was associated with asthma severity.

DISCUSSION

Asthma interventions for rural families should help families focus on gaining and maintaining low asthma severity levels to enjoy an optimal quality of life. Health care providers should try to assess the child's quality of life at each asthma care visit independently of the parents.

Patterns of concordance and non-concordance with clinician recommendations and parents' explanatory models in children with asthma

OBJECTIVE

Many children with asthma do not take medications as prescribed. We studied parents of children with asthma to define patterns of non-concordance between families' use of asthma controller medications and clinicians' recommendations, examine parents' explanatory models (EMs) of asthma, and describe relationships between patterns of non-concordance and EM.

METHODS

Qualitative study using semi-structured interviews with parents of children with persistent asthma. Grounded theory analysis identified recurrent themes and relationships between reported medication use, EMs, and other factors.

RESULTS

Twelve of the 37 parents reported non-concordance with providers' recommendations. Three types of non-concordance were identified: unintentional--parents believed they were following recommendations; unplanned--parents reported intending to give controller medications but could not; and intentional--parents stated giving medication was the wrong course of action. Analysis revealed two EMs of asthma: chronic--parents believed their child always has asthma; and intermittent--parents believed asthma was a problem their child sometimes developed.

CONCLUSIONS

Concordance or non-concordance with recommended use of medications were related to EM's and family context and took on three different patterns associated with medication underuse.

PRACTICE IMPLICATIONS

Efforts to reduce medication underuse in children with asthma may be optimized by identifying different types of non-concordance and tailoring interventions accordingly.

A 6-item brief measure for assessing perceived control of asthma in culturally diverse patients

BACKGROUND

A concise yet accurate measurement tool is needed for use in research and practice in asthma self-management perceptions across culturally diverse patient populations.

OBJECTIVES

To evaluate the psychometric properties of the 11-item Perceived Control of Asthma Questionnaire (PCAQ) and to derive a brief, psychometrically sound, and culturally sensitive measure using item response theory.

METHODS

The PCAQ was administered as one of a battery of measures to 375 adults with asthma as part of an ongoing larger project studying asthma disparities. Analyses of differential item functioning (DIF) were conducted to detect the effects of sex, race/ethnicity, and health literacy on psychometric properties.

RESULTS

Forty-eight percent of the sample was non-Hispanic white and 44% was African American. The mean +/- SD age was 43.7 +/- 13.7 years. The derived 6-item version, with 5 DIF items not scored, correlated highly with its full version (r = 0.903; P < .001).

CONCLUSIONS

The 6-item PCAQ short form has the potential to maintain scale integrity while reducing administration time and lessening survey fatigue in studies using multiple questionnaires. DIF analyses also enabled us to understand the unique aspects of perceived asthma control in demographic groups most affected by asthma.

The impact of parents' medication beliefs on asthma management

BACKGROUND

Previous studies suggest a relationship between parental beliefs about asthma medications and medication adherence. It is not clear how parents' positive and negative feelings about medications interact to influence medication adherence.

OBJECTIVES

The objectives of this study were to describe parents' perceived need for and concerns about their child's asthma medications and to assess the weighted impact of these positive and negative beliefs on parent-reported adherence.

METHODS

We conducted a cross-sectional survey of parents of children with asthma in southeast Michigan; response rate was 71%. Children with reported use of a preventive asthma medication were included (n = 622). We used a validated Beliefs About Medications Questionnaire (2 subscales: necessity and concern) to assess parents' positive and negative attitudes about their child's medications. To measure how parents weigh these beliefs, we also calculated a necessity-concern differential score (difference between necessity and concern subscales). We used a 4-item parent-report scale to measure medication adherence.

RESULTS

The majority of children were nonminority. Overall, 72% of parents felt that their child's asthma medications were necessary, and 30% had strong concerns about the medications. For 77% of parents, necessity scores were higher than concern scores, and for 17%, concern exceeded necessity. Nonminority parents were more likely to have necessity scores exceed concern scores compared with minority parents (79% vs 68%). Mean adherence scores increased as the necessity-concern differential increased. In a multivariate mixed-model regression, a greater necessity-concern differential score and being nonminority predicted better adherence.

CONCLUSIONS

These findings confirm a relationship between medication beliefs and adherence among parents of children with asthma. A better understanding of parents' medication beliefs and their impact on adherence may help clinicians counsel effectively to promote adherence.

Parents' specific concerns about daily asthma medications for children

Specific concerns from 706 parents regarding their children's (M age = 8.0, SD = 3.9) use of daily asthma medications were systematically identified and organized. 270 (38.2%) of 706 parents expressed a total of 470 concerns (M = 1.74, SD = 0.93; Range 1-5), including concerns about side effects (48.9%; e.g., growth retardation); aspects of the regimen (29.3%; e.g., medication amount); and "steroid" use (10.4%). Independent predictors of parental concern included use of inhaled corticosteroids (OR = 1.60, 95% CI 1.07-2.40), nasal corticosteroids (OR = 1.70, 95% CI 1.21-2.38), and alternative therapies (OR = 1.84, 95% CI 1.32-2.56). Providers should be prepared to address a wide range of medication concerns, especially those related to side effects.

The impact of the parental illness representation on disease management in childhood asthma

BACKGROUND

Despite significant advances in treatment modalities, morbidity due to childhood asthma has continued to increase, particularly for poor and minority children.

OBJECTIVES

To describe the parental illness representation of asthma in juxtaposition to the professional model of asthma and to evaluate the impact of that illness representation on the adequacy of the child's medication regimen.

METHODS

Parents (n = 228) of children with asthma were interviewed regarding illness beliefs using a semistructured interview. The impact of background characteristics, parental beliefs, the child's symptom interpretation, and the parent-healthcare provider (HCP) relationship on the adequacy of the child's medication regimen were evaluated.

RESULTS

The parental and professional models of asthma differ markedly. Demographic risk factors (p = .005), low parental education (p < .0001), inaccurate symptom evaluation by the child (p = .02), and a poor parent-HCP relationship (p < .0001) had a negative effect on the parental illness representation. A parental illness representation concordant with the professional model of asthma (p = .05) and more formal asthma education (p = .02) had a direct positive effect on the medication regimen. Demographic risk factors (p = .006) and informal advice-seeking (p = .0003) had a negative impact on the regimen. The parental illness representation mediated the impact of demographic risk factors (p = .10), parental education (p =.07), and the parent-HCP relationship (p = .06) on the regimen.

DISCUSSION

Parents and HCPs may come to the clinical encounter with markedly different illness representations. Establishing a partnership with parents by eliciting and acknowledging parental beliefs is an important component of improving disease management.

Patterns of inhaled antiinflammatory medication use in young underserved children with asthma

BACKGROUND

Asthma guidelines advocate inhaled corticosteroids as the cornerstone treatment of persistent asthma, yet several studies report underuse of inhaled corticosteroids in children with persistent asthma. Moreover, few studies use objective pharmacy data as a measure of drug availability of asthma medications. We examined factors associated with the use of inhaled corticosteroids in young underserved children with persistent asthma using pharmacy records as their source of asthma medications.

METHODS

This was a cross-sectional analysis of questionnaire and pharmacy record data over a 12-month period from participants enrolled in a randomized clinical trial of a nebulizer educational intervention.

RESULTS

Although exposure to > or = 1 inhaled corticosteroids refill was high at 72%, 1 of 5 children with persistent asthma had either no medication or only short-acting beta agonist fills for 12 months. Only 20% of children obtained > or = 6 inhaled corticosteroids fills over 12 months. Obtaining > or = 3 inhaled corticosteroids fills over 12 months was significantly associated with an increase in short-acting beta agonist fills and receiving specialty care in the regression models while controlling for child age, asthma severity, number of emergency department visits, having an asthma action plan, and seeking preventive care for the child's asthma.

CONCLUSIONS

Overreliance on short-acting beta agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills.

The Breathmobile Program: structure, implementation, and evolution of a large-scale, urban, pediatric asthma disease management program

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.

Parental beliefs about medications and medication adherence among urban children with asthma

BACKGROUND

Although national guidelines recommend controller medications for children with persistent asthma, adherence is poor. Prior studies have begun to explore parental beliefs regarding controller asthma medications and their effect on adherence.

OBJECTIVE

To describe parental beliefs about controller medications among a community-based sample of urban children with persistent asthma and to examine the relationship between parental beliefs and adherence.

DESIGN/METHODS

Parents of 150 children with asthma completed a telephone survey as part of a larger asthma intervention. Parents of children using controller asthma medications were included in this study. A previously validated Beliefs About Medications Questionnaire (BMQ) was used, which included two subscales: necessity and concern. The relationship between parental beliefs about medications and medication adherence was assessed using bivariate linear regression and multivariate statistics.

RESULTS

This study included 67 children with parental report of controller medication (54% male, 61% African American, 69% Medicaid). Overall, 75% of parents strongly believed that their child's medications were necessary for their health and 34% had strong concerns about the medications. Only 22% of parents reported being completely adherent with medications. Parents with greater concern about medications were more likely to have poor adherence (P < .05). In a multivariate analysis, including both BMQ subscales and asthma severity, concern about medications significantly predicted poor medication adherence (P = .03).

CONCLUSIONS

Parental concerns about controller medications were associated with poor medication adherence for this population of urban children with asthma. These findings highlight the importance of addressing parental concerns at the time of medication prescription.