Feasibility and impact of a school-based intervention for families of urban adolescents with asthma: results from a randomized pilot trial

Psychological interventions for asthma in children and adolescents

BACKGROUND

Rates of asthma are high in children and adolescents, and young people with asthma generally report poorer health outcomes than those without asthma. Young people with asthma experience a range of challenges that may contribute to psychological distress. This is compounded by the social, psychological, and developmental challenges experienced by all people during this life stage. Psychological interventions (such as behavioural therapies or cognitive therapies) have the potential to reduce psychological distress and thus improve behavioural outcomes such as self-efficacy and medication adherence. In turn, this may reduce medical contacts and asthma attacks.

OBJECTIVES

To determine the efficacy of psychological interventions for modifying health and behavioural outcomes in children with asthma, compared with usual treatment, treatment with no psychological component, or no treatment.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register (including CENTRAL, CRS, MEDLINE, Embase, PsycINFO, CINAHL EBSCO, AMED EBSCO), proceedings of major respiratory conferences, reference lists of included studies, and online clinical databases. The most recent search was conducted on 22 August 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing psychological interventions of any duration with usual care, active controls, or a waiting-list control in male and female children and adolescents (aged five to 18 years) with asthma.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. symptoms of anxiety and depression, 2. medical contacts, and 3. asthma attacks. Our secondary outcomes were 1. self-reported asthma symptoms, 2. medication use, 3. quality of life, and 4. adverse events/side effects.

MAIN RESULTS

We included 24 studies (1639 participants) published between 1978 and 2021. Eleven studies were set in the USA, five in China, two in Sweden, three in Iran, and one each in the Netherlands, UK, and Germany. Participants' asthma severity ranged from mild to severe. Three studies included primary school-aged participants (five to 12 years), two included secondary school-aged participants (13 to 18 years), and 18 included both age groups, while one study was unclear on the age ranges. Durations of interventions ranged from three days to eight months. One intervention was conducted online and the rest were face-to-face. Meta-analysis was not possible due to clinical heterogeneity (interventions, populations, outcome tools and definitions, and length of follow-up). We tabulated and summarised the results narratively with reference to direction, magnitude, and certainty of effects. The certainty of the evidence was very low for all outcomes. A lack of information about scale metrics and minimal clinically important differences for the scales used to measure anxiety, depression, asthma symptoms, medication use, and quality of life made it difficult to judge clinical significance. Primary outcomes Four studies (327 participants) reported beneficial or mixed effects of psychological interventions versus controls for symptoms of anxiety, and one found little to no difference between groups (104 participants). Two studies (166 participants) that evaluated symptoms of depression both reported benefits of psychological interventions compared to controls. Three small studies (92 participants) reported a reduction in medical contacts, but two larger studies (544 participants) found little or no difference between groups in this outcome. Two studies (107 participants) found that the intervention had an important beneficial effect on number of asthma attacks, and one small study (22 participants) found little or no effect of the intervention for this outcome. Secondary outcomes Eleven studies (720 participants) assessed asthma symptoms; four (322 participants) reported beneficial effects of the intervention compared to control, five (257 participants) reported mixed or unclear findings, and two (131 participants) found little or no difference between groups. Eight studies (822 participants) reported a variety of medication use measures; six of these studies (670 participants) found a positive effect of the intervention versus control, and the other two (152 participants) found little or no difference between the groups. Across six studies (653 participants) reporting measures of quality of life, the largest three (522 participants) found little or no difference between the groups. Where findings were positive or mixed, there was evidence of selective reporting (2 studies, 131 participants). No studies provided data related to adverse effects.

AUTHORS' CONCLUSIONS

Most studies that reported symptoms of anxiety, depression, asthma attacks, asthma symptoms, and medication use found a positive effect of psychological interventions versus control on at least one measure. However, some findings were mixed, it was difficult to judge clinical significance, and the evidence for all outcomes is very uncertain due to clinical heterogeneity, small sample sizes, incomplete reporting, and risk of bias. There is limited evidence to suggest that psychological interventions can reduce the need for medical contact or improve quality of life, and no studies reported adverse events. It was not possible to identify components of effective interventions and distinguish these from interventions showing no evidence of an effect due to substantial heterogeneity. Future investigations of evidence-based psychological techniques should consider standardising outcomes to support cross-comparison and better inform patient and policymaker decision-making.

Supporting adolescents living with HIV within boarding schools in Kenya

Adolescents and youth living with HIV (AYLHIV) are a uniquely vulnerable population facing challenges around adherence, disclosure of HIV status and stigma. Providing school-based support for AYLHIV offers an opportunity to optimize their health and wellbeing. The purpose of this study was to evaluate the feasibility of school-based supportive interventions for AYLHIV in Kenya. From 2016-2019, with funding from ViiV Healthcare, the Elizabeth Glaser Pediatric AIDS Foundation implemented the innovative Red Carpet Program (RCP) for AYLHIV in participating public healthcare facilities and boarding schools in Homa Bay and Turkana Counties in Kenya. In this analysis, we report the implementation of the school-based interventions for AYLHIV in schools, which included: a) capacity building for overall in-school HIV, stigma and sexual and reproductive health education; b) HIV care and treatment support; c) bi-directional linkages with healthcare facilities; and d) psychosocial support (PSS). Overall, 561 school staff and 476 school adolescent health advocates received training to facilitate supportive environments for AYLHIV and school-wide education on HIV, stigma, and sexual and reproductive health. All 87 boarding schools inter-linked to 66 regional healthcare facilities to support care and treatment of AYLHIV. Across all RCP schools, 546 AYLHIV had their HIV status disclosed to school staff and received supportive care within schools, including treatment literacy and adherence counselling, confidential storage and access to HIV medications. School-based interventions to optimize care and treatment support for AYLHIV are feasible and contribute to advancing sexual and reproductive health within schools.

Using Mobile Health to Improve Asthma Self-Management in Early Adolescence: A Pilot Randomized Controlled Trial

PURPOSE

Early adolescence is an important developmental period where youth take primary responsibility for asthma self-management. Helpful caregiver support during this time is pivotal in determining whether early adolescents successfully develop asthma self-management behaviors. AIM2ACT is a dyadic mobile health intervention designed to increase helpful caregiver support as early adolescents engage in asthma self-management behaviors. We conducted a pilot randomized controlled trial to determine the feasibility and acceptability of AIM2ACT and conduct preliminary tests of efficacy.

METHODS

We randomized adolescents (12-15 years old) and a caregiver to receive AIM2ACT (n = 17) or a self-guided attention control condition (n = 16) for 20 weeks. We conducted assessment visits at baseline, postintervention, and 4-month follow-up. Outcomes included family asthma management (primary outcome), adolescent asthma control, lung function (forced expiratory volume in 1 second), asthma-related quality of life, asthma management self-efficacy, and family communication.

RESULTS

We randomized 33 dyads and had 100% retention in the trial among AIM2ACT participants. Dyads frequently engaged with AIM2ACT (M = 21 days for adolescents, 32.65 days for caregivers) and reported very high satisfaction with content, functionality, and helpfulness. Participants randomized to AIM2ACT had significant improvements in asthma control scores (p = .04) compared to control that surpassed the minimally clinically important difference threshold. Although not statistically significant, the magnitude of improvements in family asthma management, asthma-related quality of life, and family communication was larger in the AIM2ACT group.

CONCLUSIONS

AIM2ACT is a feasible and acceptable dyadic mobile health asthma self-management intervention that improves asthma control.

Psychological burden of asthma in adolescents and their parents

INTRODUCTION

Asthma, a common chronic disease in adolescents is impacted by factors affecting quality of life. This study aimed to determine the psychosocial factors of adolescents with asthma and their parents.

METHODS

The study included 122 adolescents with asthma, 82 healthy controls, and their parents who completed the Asthma Control Test (ACT), Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and the Brief Symptom Inventory (BSI).

RESULTS

The mean age was 14.2 ± 1.9 years. ACT score was high and depression was low in patients with good treatment compliance. As the age of the first asthma symptoms/diagnosis increased, somatization, anxiety, hostility and general psychopathology scores increased, as did the somatization score of parents. Parental anxiety score was not related with adolescent BSI scores in the controls but in the study group when it was higher, the anxiety, depression, somatization, and general psychopathology scores were higher. PAQLQ showed that anxiety, negative self-esteem, somatization, depression, and general psychopathology were higher in patients concerned about asthma. Depression and somatization scores were higher in the parents of patients who perceived that "Treatment does not contribute to asthma control." Somatization scores were higher among parents of patients who noted: "Asthma will not pass in the long-term" and "I cannot control asthma."

CONCLUSION

Higher scores of asthma patients who were anxious about the disease and families who were despondent about treatment demonstrate that health care providers should spend more time informing patients and caregivers. Increasing patient treatment compliance during early adolescence will lessen the psychological burden of the disease.

Do guidelines provide evidence-based guidance to health professionals on promoting developmentally appropriate chronic condition self-management in children? A systematic review

OBJECTIVES

To determine whether evidence-based practice guidelines promote developmentally appropriate chronic condition self-management for children with asthma, type 1 diabetes mellitus, and cystic fibrosis.

METHODS

Systematic review of clinical guidelines current as at 22 September 2017, including assessment of quality of each guideline using the iCAHE 'Guideline Quality Checklist', and mapping of the supporting evidence.

RESULTS

Fifteen guidelines were identified: asthma (n=7) and type 1 diabetes mellitus (n=7), CF (n=1). Guideline quality was variable, and 11 different grading systems were used. In total, there were 28 recommendations promoting age/developmental considerations. Recommendations focused on: collaboration (n=15), chronic condition self-management education (n= 17), clinicians' skills (n= 4); personalized action plans (n=3), problem-solving (n=2); and the assessment of children's chronic condition self-management needs (n=3). Developmental transitions are highlighted as important time points in some guidelines: preschool (n=2), and adolescence (n=3). All guidelines encouraged triadic partnerships between children, adult caregivers and clinicians. Evidence supporting the developmental aspects of the guidelines' recommendations was poor; only 14 out of 57 journals listed as evidence were concordant.

DISCUSSION

Current guidelines articulate that developmentally appropriate chronic condition self-management is important; however, more work needs to be done to translate the concept into practical clinical tools.

EAACI Guidelines on the effective transition of adolescents and young adults with allergy and asthma

Adolescent and young adult (AYA) patients need additional support, while they experience the challenges associated with their age. They need specific training to learn the knowledge and skills required to confidently self-manage their allergies and/or asthma. Transitional care is a complex process, which should address the psychological, medical, educational and vocational needs of AYA in the developmentally appropriate way. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline to provide evidence-based recommendations for healthcare professionals to support the transitional care of AYA with allergy and/or asthma. This guideline was developed by a multidisciplinary working panel of experts and patient representatives based on two recent systematic reviews. It sets out a series of general recommendations on operating a clinical service for AYA, which include the following: (a) starting transition early (11-13 years), (b) using a structured, multidisciplinary approach, (c) ensuring AYA fully understand their condition and have resources they can access, (d) active monitoring of adherence and (e) discussing any implications for further education and work. Specific allergy and asthma transition recommendations include (a) simplifying medication regimes and using reminders; (b) focusing on areas where AYA are not confident and involving peers in training AYA patients; (c) identifying and managing psychological and socio-economic issues impacting disease control and quality of life; (d) enrolling the family in assisting AYA to undertake self-management; and (e) encouraging AYA to let their friends know about their allergies and asthma. These recommendations may need to be adapted to fit into national healthcare systems.

The effectiveness of interventions to improve self-management for adolescents and young adults with allergic conditions: A systematic review

BACKGROUND

This systematic review aimed to review the literature on interventions for improving self-management and well-being in adolescents and young adults (11-25 years) with asthma and allergic conditions.

METHODS

A systematic literature search was undertaken across eight databases. References were checked by two reviewers for inclusion. Study data were extracted, and their quality was assessed in duplicate. A narrative synthesis was undertaken.

RESULTS

A total of 30 papers reporting data from 27 studies were included. Interventions types were psychological (k = 9); e-health (k = 8); educational (k = 4); peer-led (k = 5); breathing re-training (k = 1). All interventions were for asthma. Psychological interventions resulted in significant improvements in the intervention group compared with the control group for self-esteem, quality of life, self-efficacy, coping strategies, mood and asthma symptoms. E-Health interventions reported significant improvements for inhaler technique, adherence and quality of life. General educational interventions demonstrated significantly improved quality of life, management of asthma symptoms, controller medication use, increased use of a written management plan and reduction in symptoms. The peer-led interventions included the Triple A (Adolescent Asthma Action) programme and a peer-led camp based on the Power Breathing Programme. Improvements were found for self-efficacy, school absenteeism and quality of life.

CONCLUSION

Although significant improvements were seen for all intervention types, many were small feasibility or pilot studies, few studies reported effect sizes and no studies for allergic conditions other than asthma met the inclusion criteria. Research using large longitudinal interventional designs across the range of allergic conditions is required to strengthen the evidence base.

Developmentally appropriate supported self-management for children and young people with chronic conditions: A consensus

OBJECTIVE/S

To create a consensus list of self-management definitions, recommendations, and endpoints for children and young people (0-20 years) with chronic conditions.

METHODS

This study used a Delphi technique. Based on the number of relevant peer-reviewed publications, clinical academics were invited to participate in three survey rounds. Round one contained open-ended and multiple-choice questions eliciting general opinions on self-management. For round two, results were provided to the interdisciplinary expert panel as statements for rating their agreement using a 7-point Likert scale, with consensus predefined as moderately or extremely satisfied by >70% of participants. Statements not meeting consensus were re-presented in round three, with group feedback incorporated. Finalised statements informed creation of the 'Partners in Health: Self-Management Consensus List for Children and Young People'.

RESULTS

Sixteen clinical academics participated: 12 completed round one; 14 completed round two; and 12 completed round three. Of 101 statements, 90 reached consensus, with statements separated into five developmentally appropriate groups. Statements covered broad self-management and self-management support domains including knowledge, involvement, monitoring/responding to symptoms, transition, impact, lifestyle, and support. Division of responsibility and autonomy were distinct themes.

CONCLUSION AND PRACTICE IMPLICATIONS

This research provides consensus-based guidance for clinicians providing paediatric self-management support.

They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity

Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.

Randomized clinical trial of parental psychosocial stress management to improve asthma outcomes

OBJECTIVE

Because higher parental psychosocial stress is associated with worsened asthma outcomes in children, we sought to determine if a parent-focused stress management intervention would improve outcomes among their at-risk African American children.

METHODS

We enrolled self-identified African American parent-child dyads (children aged 4-12 years old with persistent asthma, no co-morbidities, on Medicaid) in a prospective, single-blind, randomized clinical trial with follow-up at 3, 6, and 12 months. All children received care based on the guidelines of the National Institutes of Health. Developed with extensive local stakeholder engagement, the intervention consisted of four individual sessions with a community wellness coach (delivered over 3 months) supplemented with weekly text messaging and twice monthly group sessions (both delivered for 6 months). The main outcome was asthma symptom-free days in the prior 14 days by repeated measures at 3 and 6 months follow-up.

RESULTS

We randomized 217 parent-child dyads and followed 196 (90.3%) for 12 months. Coaches completed 338/428 (79%) of all individual sessions. Symptom-free days increased significantly from baseline in both groups at 3, 6, and 12 months, but there were no significant differences between groups over the first 6 months. At 12 months, the intervention group sustained a significantly greater increase in symptom-free days from baseline [adjusted difference = 0.92 days, 95% confidence interval (0.04, 1.8)].

CONCLUSION

The intervention did not achieve its primary outcome. The efficacy of providing psychosocial stress management training to parents of at-risk African American children with persistent asthma in order to improve the children's outcomes may be limited.

CLINICALTRIALS.GOV

NCT02374138.

What are the components of effective chronic condition self-management education interventions for children with asthma, cystic fibrosis, and diabetes? A systematic review

OBJECTIVE

To articulate the components of educational interventions that help children learn about managing their asthma, cystic fibrosis, or diabetes, relevant to their age/developmental status.

METHODS

A systematic review of chronic condition self-management (CCSM) educational interventions that included age/developmentally appropriate components, published before 27 January 2018, including evidence level and quality assessments. Teaching approaches were extracted and translated into practical components.

RESULTS

Twenty education interventions were identified, published across 30 studies. Most studies (n = 20/30) were based on the theories of Piaget and Bandura. Similar teaching approaches were used across conditions, incorporating sequenced curriculum and a variety of active elements. Age/developmentally appropriate interventions resulted in improvements in the CCSM capabilities of children. Outcomes were improved when compared with usual care. For very young children, educational interventions were directed at parents/families. As children reached school age, interventions increasingly became child-focused, promoting autonomy. Integrated play and reinforcement were common. Adolescent interventions placed greater emphasis on communication, problem-solving, and role division.

CONCLUSION

Eight key components were identified: structured and sequenced curricula; reinforcement; active participation; collaboration; autonomy; feedback; multiple exposures; and, problem-solving. Different components are relevant to specific life stages.

PRACTICE IMPLICATIONS

Clinicians require age/developmentally appropriate practical education tools to provide effective paediatric health care.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies for parents of children and adolescents with chronic illness aim to improve parenting behavior and mental health, child functioning (behavior/disability, mental health, and medical symptoms), and family functioning.This is an updated version of the original Cochrane Review (2012) which was first updated in 2015.

OBJECTIVES

To evaluate the efficacy and adverse events of psychological therapies for parents of children and adolescents with a chronic illness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and trials registries for studies published up to July 2018.

SELECTION CRITERIA

Included studies were randomized controlled trials (RCTs) of psychological interventions for parents of children and adolescents with a chronic illness. In this update we included studies with more than 20 participants per arm. In this update, we included interventions that combined psychological and pharmacological treatments. We included comparison groups that received either non-psychological treatment (e.g. psychoeducation), treatment as usual (e.g. standard medical care without added psychological therapy), or wait-list.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcomes post-treatment and at first available follow-up. Primary outcomes were parenting behavior and parent mental health. Secondary outcomes were child behavior/disability, child mental health, child medical symptoms, and family functioning. We pooled data using the standardized mean difference (SMD) and a random-effects model, and evaluated outcomes by medical condition and by therapy type. We assessed risk of bias per Cochrane guidance and quality of evidence using GRADE.

MAIN RESULTS

We added 21 new studies. We removed 23 studies from the previous update that no longer met our inclusion criteria. There are now 44 RCTs, including 4697 participants post-treatment. Studies included children with asthma (4), cancer (7), chronic pain (13), diabetes (15), inflammatory bowel disease (2), skin diseases (1), and traumatic brain injury (3). Therapy types included cognitive-behavioural therapy (CBT; 21), family therapy (4), motivational interviewing (3), multisystemic therapy (4), and problem-solving therapy (PST; 12). We rated risk of bias as low or unclear for most domains, except selective reporting bias, which we rated high for 19 studies due to incomplete outcome reporting. Evidence quality ranged from very low to moderate. We downgraded evidence due to high heterogeneity, imprecision, and publication bias.Evaluation of parent outcomes by medical conditionPsychological therapies may improve parenting behavior (e.g. maladaptive or solicitous behaviors; lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.28, 95% confidence interval (CI) -0.43 to -0.13; participants = 664; studies = 3; SMD -0.21, 95% CI -0.37 to -0.05; participants = 625; studies = 3; I2 = 0%, respectively, low-quality evidence), chronic pain post-treatment and follow-up (SMD -0.29, 95% CI -0.47 to -0.10; participants = 755; studies = 6; SMD -0.35, 95% CI -0.50 to -0.20; participants = 678; studies = 5, respectively, moderate-quality evidence), diabetes post-treatment (SMD -1.39, 95% CI -2.41 to -0.38; participants = 338; studies = 5, very low-quality evidence), and traumatic brain injury post-treatment (SMD -0.74, 95% CI -1.25 to -0.22; participants = 254; studies = 3, very low-quality evidence). For the remaining analyses data were insufficient to evaluate the effect of treatment.Psychological therapies may improve parent mental health (e.g. depression, anxiety, lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.21, 95% CI -0.35 to -0.08; participants = 836, studies = 6, high-quality evidence; SMD -0.23, 95% CI -0.39 to -0.08; participants = 667; studies = 4, moderate-quality evidence, respectively), and chronic pain post-treatment and follow-up (SMD -0.24, 95% CI -0.42 to -0.06; participants = 490; studies = 3; SMD -0.20, 95% CI -0.38 to -0.02; participants = 482; studies = 3, respectively, low-quality evidence). Parent mental health did not improve in studies of children with diabetes post-treatment (SMD -0.24, 95% CI -0.90 to 0.42; participants = 211; studies = 3, very low-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent mental health.Evaluation of parent outcomes by psychological therapy typeCBT may improve parenting behavior post-treatment (SMD -0.45, 95% CI -0.68 to -0.21; participants = 1040; studies = 9, low-quality evidence), and follow-up (SMD -0.26, 95% CI -0.42 to -0.11; participants = 743; studies = 6, moderate-quality evidence). We did not find evidence for a beneficial effect for CBT on parent mental health at post-treatment or follow-up (SMD -0.19, 95% CI -0.41 to 0.03; participants = 811; studies = 8; SMD -0.07, 95% CI -0.34 to 0.20; participants = 592; studies = 5; respectively, very low-quality evidence). PST may improve parenting behavior post-treatment and follow-up (SMD -0.39, 95% CI -0.64 to -0.13; participants = 947; studies = 7, low-quality evidence; SMD -0.54, 95% CI -0.94 to -0.14; participants = 852; studies = 6, very low-quality evidence, respectively), and parent mental health post-treatment and follow-up (SMD -0.30, 95% CI -0.45 to -0.15; participants = 891; studies = 6; SMD -0.21, 95% CI -0.35 to -0.07; participants = 800; studies = 5, respectively, moderate-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent outcomes.Adverse eventsWe could not evaluate treatment safety because most studies (32) did not report on whether adverse events occurred during the study period. In six studies, the authors reported that no adverse events occurred. The remaining six studies reported adverse events and none were attributed to psychological therapy. We rated the quality of evidence for adverse events as moderate.

AUTHORS' CONCLUSIONS

Psychological therapy may improve parenting behavior among parents of children with cancer, chronic pain, diabetes, and traumatic brain injury. We also found beneficial effects of psychological therapy may also improve parent mental health among parents of children with cancer and chronic pain. CBT and PST may improve parenting behavior. PST may also improve parent mental health. However, the quality of evidence is generally low and there are insufficient data to evaluate most outcomes. Our findings could change as new studies are conducted.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Changes in asthma self-management knowledge in inner city adolescents following developmentally sensitive self-management training

OBJECTIVE

To evaluate efficacy of a developmentally sensitive curriculum for improving asthma self-management knowledge, attitude, and self-efficacy in adolescents.

METHODS

Fourty-two inner-city adolescents (ages 16-20) participated in a 12hour asthma self-management training program. Self-management knowledge, attitude toward asthma, and asthma-related self-efficacy were measured using short-answer tests before and after training. T-Tests were used to evaluate impact and effect sizes were calculated.

RESULTS

Mean pretest knowledge was 21.37/46 points; mean posttest was 36.33/46 points. Change from pre- to posttest was highly significant (t=10.34; p<0.0001), with a large effect size (d=1.68). Females improved more than males (18.66±8.58 vs. 12.29±8.13, p=0.039). Greatest effects were seen in awareness of long-term consequences of uncontrolled asthma (d=2.04), ability to recognize symptoms of life-threatening asthma (d=1.61), correctly monitor symptoms (d=1.49), and tell if asthma was uncontrolled (d=1.39). Asthma self-efficacy also improved significantly (p=0.017), particularly confidence in ability to correctly manage asthma, however improvements in attitude did not achieve statistical significance.

CONCLUSION

Developmentally appropriate training is effective in increasing critical self-management knowledge and self-efficacy in inner city adolescents, particularly females.

PRACTICE IMPLICATIONS

Providers should screen carefully for symptoms and educate using developmentally appropriate training materials on ways to correctly monitor and manage symptom.

Effectiveness of school-based family asthma educational programs in quality of life and asthma exacerbations in asthmatic children aged five to 18: a systematic review

BACKGROUND

Asthma is a common, chronic, non-communicable respiratory disease that affects millions of children worldwide. Asthma exacerbations can range from mild to severe and can have an unfavorable impact on the quality of life of children and their caregivers. Asthma exacerbations often result in absenteeism from school or work, activity intolerance and emergency hospital visits. One strategy to address this health issue in an attempt to improve health outcomes is school-based asthma educational programs. A review of the literature revealed that previous systematic reviews have examined similar topics on the effectiveness of school-based asthma educational programs that have included collaborative efforts between parents and schools. No systematic reviews were found that examined the effectiveness of school-based asthma educational programs that exclusively included children and their caregivers. Research has not been systematically reviewed to determine the effectiveness of a school-based asthma educational program within a familial context.

OBJECTIVES

To identify the best available evidence on the effectiveness of school-based family asthma educational programs that exclusively included both children and caregivers on the quality of life and number of asthma exacerbations of children aged five to 18 years with a clinical diagnosis of asthma.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Children aged five to 18 years of any gender, race or ethnicity with a clinical diagnosis of asthma and their caregivers.

TYPES OF INTERVENTION(S)

School-based family asthma educational programs.

TYPES OF STUDIES

Randomized controlled trials.

OUTCOMES

Quality of life and the number of asthma exacerbations measured by either missed days from school or work, and/or physical activity intolerance, and/or emergency hospital visits.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies from inception of the database to August 21, 2015.

METHODOLOGICAL QUALITY

Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity before inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Data were extracted from articles included in the review using the standardized data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the populations, interventions, study methods and outcomes of significance to the review question and its specific objectives.

DATA SYNTHESIS

Due to the heterogeneity among the included studies, statistical pooling and meta-analysis was not possible. Results are presented in narrative form.

RESULTS

Six studies examining the intervention were included in this review. All six of the included studies were randomized controlled trials (RCTs). All six studies compared the effects of school-based asthma education to no school-based asthma education/usual care on quality of life and number of asthma exacerbations. Three out of four RCTs showed that children who participated in school-based family asthma educational programs demonstrated a statistically significant improvement in overall quality of life (P < 0.05). All six studies showed improvement in the number of asthma exacerbations that resulted in one or all of the measured outcomes of either missed days from school or work, physical activity intolerance and/or decreased emergency hospital visits.

CONCLUSION

School-based family asthma educational programs for children that include caregivers can have a positive impact on the quality of life and asthma management of children with asthma. Other outcomes that can be positively affected by school-based family asthma educational programs include absenteeism from school or work, physical activity intolerance and emergency hospital visits as result of asthma exacerbations.

The effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to 18 years diagnosed with asthma: a systematic review protocol

REVIEW OBJECTIVE

The objective of this review is to identify the best available quantitative evidence related to the effectiveness of school-based family asthma educational programs on the quality of life and number of asthma exacerbations of children aged five to18 years with a diagnosis of asthma.

BACKGROUND

Asthma is a serious public health issue globally and nationally. The World Health Organization (WHO) Global Asthma Report 2014 estimates that 334 million people worldwide currently suffer from asthma. In the United States, asthma currently affects about 25 million people. Although asthma can occur at any age, it most often begins early in life, and is the most common non-communicable disease among children. Approximately 14% of the world's children have asthma. In the United States, 7.1 million children have asthma. Globally, the burden of asthma, measured by disability and premature death, is greatest in children approaching adolescence (ages 10-14). Asthma is also a serious economic concern in primary health care worldwide. In the United States, the estimated total cost of asthma to society was US$56 billion in 2007, or US$3259 per person. In 2008 asthma caused 10.5 million missed days from school and 14.2 missed days from work for caregivers. The estimated total cost of loss of productivity resulting from missed school or work days is US$3.8 billion per year, and premature death US$2.1 billion per year. Globally, asthma ranks 14 in terms of disability adjusted life years (DALYs), which are the number of years lost to ill health, disability or death attributed to asthma. According to a 2011 European study, the estimated total cost of asthma was €19.3 billion among people aged 15 to 64 years. A study conducted in the Asia-Pacific region reported that the direct and indirect costs of asthma per person ranged from US$184 in Vietnam to US$1189in Hong Kong in 2000. A Canadian study showed that C$184 loss of productivity during one week was attributed to asthma in 2012. In Australia, AU$655 million was spent on asthma for 2008-09.Asthma is a chronic respiratory disease that affects millions of people of all ethnicities, ages and genders worldwide. The pathophysiology of asthma is multifaceted, and is characterized by restriction of airflow into and out of the lungs, airway inflammation with increased mucus production, and bronchial hyper-reactivity caused by exposure to environmental irritants and chemicals, often referred to as triggers, which in some cases are modifiable. Asthma triggers include respiratory infections, weather changes, stress, excitement, exercise and other physical activities, allergic hypersensitivity reactions, food additives, animal dander, dust mites, cockroaches, outdoor and indoor pollutants, certain medications and cigarette smoke. Asthma is characterized by recurrent, episodic, reversible symptoms often referred to as asthma exacerbations, or asthma attacks. Asthma symptoms include coughing, shortness of breath, chest tightness and wheezing that most frequently occur at night or in the early morning. Asthma symptoms vary in severity and frequency in affected individuals, and can occur several times a day or week. Asthma symptoms may be mild, moderate, or severe, and are classified according to presenting symptoms and quantitative measurements of lung function using a peak expiratory flow meter (PEF), or of forced expiratory volume in one second (FEV1). Asthma symptoms can be so severe that, if left untreated, death can occur.Exacerbations of asthma symptoms often result in school and work absenteeism, activity intolerance and emergency hospital visits for asthma. Nocturnal asthma exacerbations frequently cause sleeplessness, which may result in daytime fatigue. Asthma symptoms can interfere and disrupt activities of daily life, and can have an unfavorable impact on the quality of life for people with the disease, including children and their caregivers. For this review, quality of life represents how well the asthmatic child is able to manage symptoms of the disease and lead a normal healthy life. Caregiver refers to the primary person who takes care of a child with asthma. Family refers to the caregiver and the child.According to the United States Centers for Disease Control and Prevention (CDC), epidemiologists and clinical researchers concur that the burden of asthma is higher among children compared to adults. Asthma prevalence in children varies within and across countries. Asthma disparities also exist along ethnic and racial lines. The International Study of Asthma and Allergies in Childhood (ISAAC) quantified the prevalence of asthma symptoms of children from around the world. In the United States, non-Hispanic Black and Puerto Rican children have higher asthma prevalence compared to Caucasian children. Children from the Ivory Coast, Costa Rica and Wales have higher asthma prevalence compared to children from Kenya, Brazil and England respectively. Indigenous Australians, Aboriginal and Torres Strait Islander Australian children have a higher prevalence of asthma compared to non-Indigenous Australian children. The international prevalence of asthma prompted governments and communities to create initiatives and strategies to address this public health issue.The global burden of asthma led to the development of the Global Initiative for Asthma (GINA). Formed in 1993, in collaboration with theNational Heart, Lung, and Blood Institute, National Institutes of Health, United States of America and the WHO, GINA's goals include working with healthcare providers and public health officials worldwide to reduce asthma prevalence, morbidity and mortality. In an effort to increase public awareness of the global burden of asthma, GINA created World Asthma Day, which is held annually on the first Tuesday in May. The burden of asthma in the United States fostered the creation of the National Asthma Education and Prevention Program (NAEPP). This program is designed to raise awareness about asthma and the major public health concern it poses to society. In addition to conducting asthma prevention activities, NAEPP collaborates with other stakeholders to develop asthma educational programs for minority populations who are disproportionately affected by asthma. The program believes that adequate control of asthma, through modern treatment and educational programs, can be reinforced by the development of partnerships with caregivers, schools and healthcare providers. The NAEPP Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma (EPR-3), has a provision that specifies that asthma education programs for children should include their caregivers. Caregivers' involvement is crucial for achieving the goals of asthma management in children, which supports the interest of GINA and NAEPP to include caregivers in school-based asthma education programs for children. The guidelines recommend education for asthma management should occur at all points of care, including schools. According to the EPR-3, schools are ideal locations to facilitate asthma education programs because they provide access to large numbers of children in an environment in which they are accustomed to learning. The long term effects of these approaches are improved healthcare practices, reduced mortality and morbidity, and reduced costs of asthma care.Although there is no cure for asthma, research evidence has demonstrated that asthma symptoms can be well-controlled with the appropriate medications, adherence to treatment, avoidance of asthma triggers, and education about disease management. Research studies that have investigated the effectiveness of school-based asthma education programs that have included caregivers have demonstrated beneficial effects of these programs on the quality of life and disease management of children with asthma, versus no school-based family asthma education programs.A randomized controlled trial (RCT) conducted by Clark et al. that included 835 children and their parents examined the effects of comprehensive school-based asthma education programs on symptoms, grades and school absences, and parents' asthma management practices. The interventions consisted of six components for children, their parents, classmates and school personnel. One of the six components included "Open Airways for Schools" disease management training for children, which also included handouts and homework for the parents. One of the five interventions for the parents included school fairs with asthma care questions and answers sessions to discuss the frequency and type of asthma symptoms of their children. Results of this study demonstrated that 24 months post intervention, children from the intervention groups had better disease management, which included improved control of daytime and nighttime symptoms, and reduced absences from school and work related to asthma exacerbations, compared to the children from the control group.In another study, Bruzzese et al. conducted a pilot RCT that included 24 families. Each family consisted of an asthmatic child and a caregiver. The study examined the effects of a two-month, school-based asthma education program. The interventions consisted of six interactive 75-minute group sessions for students, held once a week for six weeks, and five 90-minute group sessions for caregivers, held once a week. The student sessions were led by a developmental psychologist, and one of the lesson topics included prevention and management of asthma. The group sessions for caregivers were led by a clinical psychologist, and one of the lesson topics included asthma self-management of their children. The interventions resulted in positive short term changes in family relations and an overall improved health status for the children. (ABSTRACT TRUNCATED)

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

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

Lay-led and peer support interventions for adolescents with asthma

BACKGROUND

Adolescents with asthma are at high risk of poor adherence with treatment. This may be compounded by activities that worsen asthma, in particular smoking. Additional support above and beyond routine care has the potential to encourage good self-management. We wanted to find out whether sessions led by their peers or by lay leaders help to reduce these risks and improve asthma outcomes among adolescents.

OBJECTIVES

To assess the safety and efficacy of lay-led and peer support interventions for adolescents with asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains reports of randomised trials obtained from multiple electronic and handsearched sources, and we searched trial registries and reference lists of primary studies. We conducted the most recent searches on 25 November 2016.

SELECTION CRITERIA

Eligible studies randomised adolescents with asthma to an intervention led by lay people or peers or to a control. We included parallel randomised controlled trials with individual or cluster designs. We included studies reported as full text, those published as abstract only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the searches, extracted numerical data and study characteristics and assessed each included study for risk of bias. Primary outcomes were asthma-related quality of life and exacerbations requiring at least a course of oral steroids. We graded the analyses and presented evidence in a 'Summary of findings' table.We analysed dichotomous data as odds ratios, and continuous data as mean differences (MD) or standardised mean differences, all with a random-effects model. We assessed clinical, methodological and statistical heterogeneity when performing meta-analyses, and we described skewed data narratively.

MAIN RESULTS

Five studies including a total of 1146 participants met the inclusion criteria for this review. As ever with systematic reviews of complex interventions, studies varied by design (cluster and individually randomised), duration (2.5 to 9 months), setting (school, day camp, primary care) and intervention content. Most risk of bias concerns were related to blinding and incomplete reporting, which limited the meta-analyses that could be performed. Studies generally controlled well for selection and attrition biases.All participants were between 11 and 17 years of age. Asthma diagnosis and severity varied, as did smoking prevalence. Three studies used the Triple A programme; one of these studies tested the addition of a smoke-free pledge; another delivered peer support group sessions and mp3 messaging to encourage adherence; and the third compared a peer-led asthma day camp with an equivalent camp led by healthcare practitioners.We had low confidence in all findings owing to risk of bias, inconsistency and imprecision. Results from an analysis of asthma-related quality of life based on the prespecified random-effects model were imprecise and showed no differences (MD 0.40, 95% confidence interval (CI) -0.02 to 0.81); a sensitivity analysis based on a fixed-effect model and a responder analysis suggested small benefit may be derived for this outcome. Most other results were summarised narratively and did not show an important benefit of the intervention; studies provided no analysable data on asthma exacerbations or unscheduled visits (data were skewed), and one study measuring adherence reported a drop in both groups. Effects on asthma control favoured the intervention but findings were not statistically significant. Results from two studies with high levels of baseline smoking showed some promise for self-efficacy to stop smoking, but overall nicotine dependence and smoking-related knowledge were not significantly better in the intervention group. Investigators did not report adverse events.

AUTHORS' CONCLUSIONS

Although weak evidence suggests that lay-led and peer support interventions could lead to a small improvement in asthma-related quality of life for adolescents, benefits for asthma control, exacerbations and medication adherence remain unproven. Current evidence is insufficient to reveal whether routine use of lay-led or peer support programmes is beneficial for adolescents receiving asthma care.Ongoing and future research may help to identify target populations for lay-led and peer support interventions, along with attributes that constitute a successful programme.

Association of Youth and Caregiver Anxiety and Asthma Care Among Urban Young Adolescents

OBJECTIVE

To examine the association of adolescent asthma-related anxiety, social anxiety, separation anxiety, and caregiver asthma-related anxiety with asthma care by urban adolescents.

METHODS

Participants were 386 ethnic minority adolescents (mean age 12.8 years) with persistent asthma and their caregivers. Adolescents reported what they do to prevent asthma symptoms and to manage acute symptoms, and if they or their caregiver is responsible for their asthma care. Adolescents completed the Youth Asthma-Related Anxiety Scale, and the social and separation anxiety subscales of the Screen for Child Anxiety and Emotional Disorders (SCARED); caregivers completed the Parent Asthma-Related Anxiety Scale. Linearity of the associations was assessed by generalized additive models. When there was no evidence for nonlinearity, linear mixed effects models were used to evaluate the effects of the predictors.

RESULTS

Adolescent asthma-related anxiety had a strong curvilinear relationship with symptom prevention (P < .001). Adolescents took more prevention steps as their anxiety increased, with a plateau at moderate anxiety. There was a linear relationship of adolescent asthma-related anxiety to symptom management (β = 0.03, P = .021) and to asthma responsibility (β = 0.11, P = .015), and of caregiver asthma-related anxiety to adolescent symptom prevention (β = 0.04, P = .001). Adolescent social and separation anxiety had weak to no relationship with asthma care. Results remained consistent when controlling for each of the other anxieties.

CONCLUSIONS

Asthma-related anxiety plays an important, independent role in asthma care. When low, adolescents may benefit from increased support from caregivers and awareness of the consequences of uncontrolled asthma. When elevated, health providers should ensure the adolescents are not assuming responsibility for asthma care prematurely.

The Impacts of Educational Asthma Interventions in Schools: A Systematic Review of the Literature

Objective. To review the literature on the impact of educational asthma interventions in schools regarding the knowledge and morbidity of the disease among children and adolescents. Methods. A systematic review was conducted for controlled clinical trials investigating the effectiveness of educational asthma interventions for students, asthmatic or nonasthmatic, families, and school staff. Databases were CENTRAL, PubMed, LILACS, MEDLINE, and SciELO. Articles published in any language were considered, in the period from 2005 to 2014, according to the PRISMA guidelines. Results. Seventeen articles were selected (N = 5,879 subjects). 94% of the interventions (16 of 17 studies) were applied in developed countries that were led by health professionals and most of them targeted asthmatics. Asthma education promotes the improvement of knowledge about the disease in at least one of the evaluated areas. 29% of the interventions (5 of 17 studies) showed a reduction of the asthma symptoms, 35% (6 of 17 studies) reduction of the hospitalization instances and emergency visits, 29% (5 of 17 studies) reduction of school absenteeism, and 41% (7 of 17 studies) increase in the quality of life of the individuals. Conclusions. Educational interventions in schools raise the awareness of asthma and weaken the impact of morbidity indicators.

Parenting Stress Related to Behavioral Problems and Disease Severity in Children with Problematic Severe Asthma

Our study examined parenting stress and its association with behavioral problems and disease severity in children with problematic severe asthma. Research participants were 93 children (mean age 13.4 ± 2.7 years) and their parents (86 mothers, 59 fathers). As compared to reference groups analyzed in previous research, scores on the Parenting Stress Index in mothers and fathers of the children with problematic severe asthma were low. Higher parenting stress was associated with higher levels of internalizing and externalizing behavioral problems in children (Child Behavior Checklist). Higher parenting stress in mothers was also associated with higher airway inflammation (FeNO). Thus, although parenting stress was suggested to be low in this group, higher parenting stress, especially in the mother, is associated with more airway inflammation and greater child behavioral problems. This indicates the importance of focusing care in this group on all possible sources of problems, i.e., disease exacerbations and behavioral problems in the child as well as parenting stress.

Overcoming Medicaid Reimbursement Barriers to Funding School Nursing Services for Low-Income Children With Asthma

BACKGROUND

School nurses can provide direct services for children with asthma, educate, and reinforce treatment recommendations to children and their families, and coordinate the school-wide response to students' asthma emergencies. Unfortunately, school-based health services today depend on an unreliable patchwork of funding. Limited state and local funds lead to extremely low nurse-to-student ratios, resulting in missed opportunities for prevention and care of asthma and other health conditions.

METHODS

We carried out a nonsystematic review of legal, government, private health foundation, and medical literature.

RESULTS

Many health services for asthma and other conditions provided in school settings are services typically covered by Medicaid and the Children's Health Insurance Program (CHIP) when offered in other settings. However, complex reimbursement rules, questionable policy guidance establishing a "free care rule," and other barriers have limited the ability of schools to seek Medicaid/CHIP reimbursement for these services. Recent legal developments may help overcome some of these barriers, and new flexibilities in Medicaid law bring opportunities for increased reimbursement of school-based health services.

CONCLUSIONS

Policymakers should call on the Centers for Medicare and Medicaid Services to abandon the "free care rule" and issue other guidance that would enable schools to appropriately obtain Medicaid reimbursement for nursing services.

Behavioral Interventions to Improve Asthma Outcomes for Adolescents: A Systematic Review

BACKGROUND

Factors at multiple ecological levels, including the child, family, home, medical care, and community, impact adolescent asthma outcomes.

OBJECTIVE

This systematic review characterizes behavioral interventions at the child, family, home, medical system, and community level to improve asthma management among adolescents.

METHODS

A systematic search of PubMed, SCOPUS, OVID, PsycINFO, CINAHL, and reference review databases was conducted from January 1, 2000, through August 10, 2014. Articles were included if the title or abstract included asthma AND intervention AND (education OR self-management OR behavioral OR technology OR trigger reduction), and the mean and/or median age of participants was between 11 and 16 years. We compared populations, intervention characteristics, study designs, outcomes, settings, and intervention levels across studies to evaluate behavioral interventions to improve asthma management for adolescents.

RESULTS

Of 1230 articles identified and reviewed, 24 articles (21 unique studies) met inclusion criteria. Promising approaches to improving adherence to daily controller medications include objective monitoring of inhaled corticosteroid adherence with allergist and/or immunologist feedback on medication-taking behavior and school nurse directly observed therapy. Efficacy at increasing asthma self-management skills was demonstrated using group interactive learning in the school setting. This systematic review is not a meta-analysis, thus limiting its quantitative assessment of studies. Publication bias may also limit our findings.

CONCLUSIONS

Novel strategies to objectively increase controller medication adherence for adolescents include allergist and/or immunologist feedback and school nurse directly observed therapy. Schools, the most common setting across studies in this review, provide the opportunity for group interactive learning to improve asthma knowledge and self-management skills.

The school environment and asthma in childhood

In this article, we discuss the relationship between environmental exposures within the school environment and pediatric asthma morbidity. This article will conclude by reviewing novel school based asthma education and therapeutic programs and environmental interventions designed to help mitigate pediatric asthma morbidity.

The Association Between Asthma and Sleep in Urban Adolescents With Undiagnosed Asthma

BACKGROUND

We examined associations between asthma and sleep in a sample of inner-city adolescents with asthma-like symptoms who are undiagnosed, and to assess the extent to which youth's report of perceived stress moderates this association.

METHODS

A total of 349 adolescents (83% girls), with a mean age of 15.8 years, and their primary caregivers participated. Large segments of the sample were Latinos (46%) or African Americans (37%). Adolescents reported on asthma-namely, rate of waking up at night due to asthma-like symptoms and perceived severity of breathing problems-and sleep, specifically sleep-wake behavior problems and daytime sleepiness during activities. Caregivers provided demographic information by telephone.

RESULTS

Night awakenings and perceived severity of breathing problems were each independently associated with sleep-wake behavior problems and daytime sleepiness during activities. Youth report of perceived stress moderated the association between perceived severity of breathing problems and sleep-wake behavior problems, and perceived severity of breathing problems and daytime sleepiness during activities.

CONCLUSIONS

Results suggest the importance of interventions that consider undiagnosed asthma and its effects on sleep indicators related to daytime functioning in this high risk group of youth. This study highlights the need for interventions that consider asthma severity, nocturnal asthma, and sleep problems among urban adolescents with no asthma diagnosis.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies have been developed for parents of children and adolescents with a chronic illness. Such therapies include interventions directed at the parent only or at parent and child/adolescent, and are designed to improve parent, child, and family outcomes. This is an updated version of the original Cochrane review published in Issue 8, 2012, (Psychological interventions for parents of children and adolescents with chronic illness).

OBJECTIVES

To evaluate the efficacy of psychological therapies that include parents of children and adolescents with chronic illnesses including painful conditions, cancer, diabetes mellitus, asthma, traumatic brain injury (TBI), inflammatory bowel diseases (IBD), skin diseases, or gynaecological disorders. We also aimed to evaluate the adverse events related to implementation of psychological therapies for this population. Secondly, we aimed to evaluate the risk of bias of included studies and the quality of outcomes using the GRADE assessment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO for randomised controlled trials (RCTs) of psychological interventions that included parents of children and adolescents with a chronic illness. Databases were searched to July 2014.

SELECTION CRITERIA

Included studies were RCTs of psychological interventions that delivered treatment to parents of children and adolescents with a chronic illness compared to an active control, waiting list, or treatment as usual control group.

DATA COLLECTION AND ANALYSIS

Study characteristics and outcomes were extracted from included studies. We analysed data using two categories. First, we analysed data by each individual medical condition collapsing across all treatment classes at two time points. Second, we analysed data by each individual treatment class; cognitive behavioural therapy (CBT), family therapy (FT), problem solving therapy (PST) and multisystemic therapy (MST) collapsing across all medical conditions. For both sets of analyses we looked immediately post-treatment and at the first available follow-up. We assessed treatment effectiveness for two primary outcomes: parent behaviour and parent mental health. Five secondary outcomes were extracted; child behaviour/disability, child mental health, child symptoms, family functioning, and adverse events. Risk of bias and quality of evidence were assessed.

MAIN RESULTS

Thirteen studies were added in this update, giving a total of 47 RCTs. The total number of participants included in the data analyses was 2985, 804 of whom were added to the analyses in the update. The mean age of the children was 14.6 years. Of the 47 RCTs, the studies focused on the following paediatric conditions: n = 14 painful conditions, n = 13 diabetes, n =10 cancer, n = 5 asthma, n = 4 TBI, and n = 1 atopic eczema. We did not identify any studies treating parents of children with gynaecological disorders or IBD. Risk of bias assessments of included studies were predominantly unclear. Evidence quality, assessed using the GRADE criteria, was judged to be of low or very low quality.Analyses of separate medical conditions, across all treatment types, revealed two beneficial effects of psychological therapies for our primary outcomes. First, psychological therapies led to improved adaptive parenting behaviour in parents of children with cancer post-treatment (standardised mean difference (SMD) -0.20, 95% confidence interval (CI) -0.36 to -0.04, Z = 2.44, p = 0.01). In addition, therapies also improved parent mental health at follow-up in this group (SMD = -0.18, 95% CI -0.32 to -0.04, Z = 2.58, p = 0.01). We did not find any effect of therapies for parent behaviour for parents of children with a painful condition post-treatment or at follow-up, or for parent mental health for parents of children with cancer, diabetes, asthma, or TBI post-treatment. For all other primary outcomes, no analysis could be conducted due to lack of data.Across all medical conditions, three effects were found for the primary outcomes of psychological therapies. PST had a beneficial effect on parent adaptive behaviour (SMD = -0.25, 95% CI -0.39 to -0.11, Z = 3.59, p < 0.01) and parent mental health (SMD= -0.24, 95% CI -0.42 to -0.05, Z = 2.50, p = 0.01) immediately post-treatment and this effect was maintained at follow-up for parent mental health (SMD= -0.19, 95% CI -0.34 to -0.04, Z = 2.55, p = 0.01). The remaining analysis for PST on parent behaviour found no effect. No effects were found for CBT post-treatment or at follow-up for either parent outcome. For FT, only one analysis could be run on parent mental health and no effect was found. Due to lack of data, the remaining analyses of primary outcomes could not be run. For MST, no parent outcomes could be analysed due to lack of data.Secondary outcome analyses are presented in the Results section. Five studies reported that there were no adverse events during the trial. The remaining 42 studies did not report adverse events.

AUTHORS' CONCLUSIONS

This update includes 13 additional studies, although our conclusions have not changed from the original version. There is little evidence for the efficacy of psychological therapies that include parents on most outcome domains of functioning, for a large number of common chronic illnesses in children. However, psychological therapies are efficacious for some outcomes. CBT that includes parents is beneficial for reducing children's primary symptoms, and PST that includes parents improved parent adaptive behaviour and parent mental health. There is evidence that the beneficial effects can be maintained at follow-up for diabetes-related symptoms in children, and for the mental health of parents of children with cancer and parents who received PST.

Asthma management self-efficacy in parents of primary school-age children

The aim of this study was to investigate asthma management self-efficacy in parents of primary school-age children with asthma and to explore possible associations between parent asthma management self-efficacy, parent and child characteristics, asthma task difficulty and asthma management responsibility. A cross-sectional descriptive survey of 113 parents was conducted to assess the level of parent asthma management self-efficacy, asthma task difficulty and confidence, asthma responsibility and socio-demographic characteristics. The findings indicate that parents had higher self-efficacy for attack prevention than attack management. Parents had higher self-efficacy for asthma management tasks that are simple, skills based and performed frequently such as medication administration and less confidence and greater difficulty with tasks associated with judgement and decision-making. Multivariate linear regression analysis identified English language, child asthma responsibility and parent education as predictors of higher asthma management self-efficacy, while an older child was associated with lower parent asthma management self-efficacy. The implications of these results for planning and targeting health education and self-management interventions for parents and children are discussed.

Evidence of high rates of undiagnosed asthma in central Ohio elementary schoolchildren

BACKGROUND

In Ohio, 14.5% of 5- to 9-year-olds and 17.3% of 10- to 17-year-olds have asthma. Moreover, there is concern that these numbers may underestimate the true disease burden. We sought to evaluate variability in asthma rates and respiratory symptoms among central Ohio fourth graders as a means to assess potential undiagnosed and undertreated asthma and its determinants.

METHODS

We recruited 13 central Ohio elementary schools representing a broad range of nonurban settings and surveyed fourth graders to estimate school-level physician-diagnosed asthma (PDA), respiratory morbidity, and home exposures to smoking and pets. We used generalized linear mixed models with random intercept for school to examine relationships among exposures, respiratory symptoms, and PDA.

RESULTS

Across the 13 schools, 94% of students participated in the survey, and the estimated asthma prevalence rate was 10.2% (N = 101 of 987). An additional 41% reported not having PDA but then went on to report symptoms consistent with asthma potentially suggestive of undiagnosed asthma. Of students with PDA, 21% reported symptoms suggestive of poorly controlled asthma. High levels of secondhand smoke (SHS) exposure were associated both with PDA (p = .05) and with respiratory symptoms (p < .0001). Students who owned a cat or a bird were more likely to report respiratory symptoms (p = .02 and p = .04, respectively).

CONCLUSIONS

We provide evidence that the already high childhood asthma public health burden in central Ohio may be underreported. Schools may be an ideal location to conduct screenings and implement environmental interventions oriented toward SHS and household pets that will yield respiratory morbidity benefits.

Accuracy of weight perception among urban early adolescents with uncontrolled asthma and their caregivers

BACKGROUND

Obesity is associated with poor asthma outcomes; weight loss improves such outcomes. Inaccurate recognition of obesity may impede weight control.

PURPOSE

We examined perception of weight by early adolescents with uncontrolled asthma and their caregivers, and tested the relationship between medical visit frequency and accuracy of perceived weight status.

METHODS

A total of 373 adolescents and their caregivers reported the adolescent's height/weight and weight perception; caregivers reported healthcare utilization. We measured height/weight. Logistic regression modeled accuracy of weight perception.

RESULTS

A total of 43.7 % of the overweight/obese adolescents and caregivers accurately perceived weight status. BMI percentile [odds ratio (OR) = 1.19, confidence interval (CI) = 1.10-1.28] and total medical visits (OR = 1.18, CI = 1.05-1.33) were associated with higher accuracy in caregivers. Total medical visits (OR = 0.84, CI = 0.74-0.96) was associated with lower accuracy in adolescents.

CONCLUSIONS

Accurate perception of weight status was poor for overweight adolescents with uncontrolled asthma and their caregivers. Frequent medical visits were associated with improved caregivers' but not adolescents' perceptions.

Adolescent Asthma Self-Management: A Concept Analysis and Operational Definition

BACKGROUND: Adolescents with asthma have a higher risk of morbidity and mortality than other age groups. Asthma self-management has been shown to improve outcomes; however, the concept of asthma self-management is not explicitly defined. METHODS: We use the Norris method of concept clarification to delineate what constitutes the concept of asthma self-management in adolescents. Five databases were searched to identify components of the concept of adolescent asthma self-management, and lists of relevant subconcepts were compiled and categorized. RESULTS: Analysis revealed 4 specific domains of self-management behaviors: (1) symptom prevention; (2) symptom monitoring; (3) acute symptom management; and (4) communication with important others. These domains of self-management were mediated by intrapersonal/cognitive and interpersonal/contextual factors. CONCLUSIONS: Based on the analysis, we offer a research-based operational definition for adolescent asthma self-management and a preliminary model that can serve as a conceptual base for further research.

Minors' attitudes toward peers with asthma: a developmental study

OBJECTIVE

Peers can play a critical role in asthma management, with attitudes toward friends with asthma hindering or supporting self-management. We explored minors' attitudes toward peers with asthma, testing if attitudes varied by grade, sex, asthma knowledge, and asthma status.

METHODS

Three hundred and eighty-one students in grades 5-11 (51% female; 51% White, non-Hispanic; 12% with asthma) read five vignettes about peers with asthma, and rated the characters on 10 adjective pairs (e.g., afraid/brave and sad/happy). Three vignettes portrayed an aspect of uncontrolled asthma (asthma-related school absence, asthma-related limited physical activity, and asthma-related school nurse visit). One vignette depicted controlled asthma; one described taking medication publically. We computed a total attitude score for each vignette and a mean attitude score across the three uncontrolled vignettes. Linear regression analyses tested the effect of each predictor (grade, sex, asthma knowledge, and asthma status) on attitudes, as well as the interaction of asthma status with the remaining three predictors.

RESULTS

Grade was the most robust predictor. Participants in higher grades tended to have more favorable attitudes toward peers with asthma, except for the controlled asthma vignette where participants in lower grades had more favorable attitudes. There were significant interactions between grade and asthma status for the stop-running-and-taking-medication-publically vignettes: among those with asthma, participants in higher grades had more favorable attitudes. Sex interacted with asthma status for the overall uncontrolled, absence, and stop-running vignettes; among those with asthma, girls had more favorable attitudes.

CONCLUSION

With increased grade, minors have better attitudes toward peers with asthma. Living with asthma may normalize asthma. Clinicians can use grade-specific findings to counsel patients.

Efficacy of the I Can Control Asthma and Nutrition Now (ICAN) pilot program on health outcomes in high school students with asthma

Asthma is the most prevalent chronic illness in childhood affecting 7 million youth. Many youth with asthma face another risk factor in obesity. Obesity, in turn, increases disorders such as asthma. Studies have recommended that asthma programs also address weight management in youth. Taking this into consideration, the I Can Control Asthma and Nutrition Now (ICAN) program is an innovative school-based program composed of (1) nutrition and weight management education, (2) asthma education, and (3) monthly reenforcement visits. This pilot study tested the initial effectiveness of the ICAN pilot program on a variety of asthma and nutrition outcomes in 25 urban minority students with asthma. Over the course of the pilot program, significant increases in asthma knowledge, asthma self-efficacy, asthma quality of life, asthma self-care, nutrition knowledge, nutrition self-efficacy, and asthma control were observed. The ICAN program has demonstrated promising preliminary results in improving nutrition and asthma health outcomes with urban minority high school students.

Adolescent asthma education programs for teens: review and summary

The purpose of this review is to describe and evaluate education programs for teens with asthma. Although asthma educational programs for children are plentiful, this is not the case for adolescents. The developmental tasks of adolescence require asthma education programs that are uniquely tailored to this age group. Although several well-designed studies appear in the literature, further research is needed to evaluate the efficacy of asthma education programs among teens. Although the quality of research varies, demonstrated program benefits include improved asthma self-management, self-efficacy, family support mechanisms, and quality of life. Practice implications point to the need for education programs in schools and camp settings that are consistent with national asthma guidelines.

The Relationship between Asthma and Obesity in Urban Early Adolescents

Asthma and obesity, which have reached epidemic proportions, impact urban youth to a great extent. Findings are inconsistent regarding their relationship; no studies have considered asthma management. We explored the association of obesity and asthma-related morbidity, asthma-related health care utilization, and asthma management in urban adolescents with uncontrolled asthma. We classified 373 early adolescents (mean age=12.8 years; 82% Hispanic or Black) from New York City public middle schools into 4 weight categories: normal (body mass index [BMI]<85th percentile); overweight (85th percentile≤BMI<95th percentile); obese (95th percentile≤BMI<97th percentile); and very obese (BMI≥97th percentile). We compared sample obesity prevalence to national estimates, and tested whether weight categories predicted caregiver reported asthma outcomes, adjusting for age and race/ethnicity. Obesity prevalence was 37%, with 28% of the sample being very obese; both rates were significantly higher than national estimates. We found no significant differences in asthma-related health care utilization or asthma management between weight categories, and a few differences in asthma-related morbidity. Relative to normal weight and obese youth, overweight youth had higher odds of never having any days with asthma-related activity limitations. They also had higher odds of never having asthma-related school absences compared with obese youth. Overweight youth with asthma-related activity limitations had more days with limitations compared with normal weight youth. Overweight, but not obese youth, missed more school due to asthma than normal weight youth. Overweight and obesity prevalence was very high in urban, Hispanic, and Black adolescents with uncontrolled asthma, but not strongly associated with asthma-related morbidity, asthma-related health care utilization, or asthma management practices.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies have been developed for parents of children and adolescents with a chronic illness. Such therapies include parent only or parent and child/adolescent, and are designed to treat parent behaviour, parent mental health, child behaviour/disability, child mental health, child symptoms and/or family functioning. No comprehensive, meta-analytic reviews have been published in this area.

OBJECTIVES

To evaluate the effectiveness of psychological therapies that include coping strategies for parents of children/adolescents with chronic illnesses (painful conditions, cancer, diabetes mellitus, asthma, traumatic brain injury, inflammatory bowel diseases, skin diseases or gynaecological disorders). The therapy will aim to improve parent behaviour, parent mental health, child behaviour/disability, child mental health, child symptoms and family functioning.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE and PsycINFO for randomised controlled trials (RCTs) of psychological interventions that included parents of children and adolescents with a chronic illness. The initial search was from inception of these databases to June 2011 and we conducted a follow-up search from June 2011 to March 2012. We identified additional studies from the reference list of retrieved papers and from discussion with investigators.

SELECTION CRITERIA

Included studies were RCTs of psychological interventions that delivered treatment to parents of children and adolescents (under 19 years of age) with a chronic illness compared to active control, wait list control or treatment as usual. We excluded studies if the parent component was a coaching intervention, the aim of the intervention was health prevention/promotion, the comparator was a pharmacological treatment, the child/adolescent had an illness not listed above or the study included children with more than one type of chronic illness. Further to this, we excluded studies when the sample size of either comparator group was fewer than 10 at post-treatment.

DATA COLLECTION AND ANALYSIS

We included 35 RCTs involving a total of 2723 primary trial participants. Two review authors extracted data from 26 studies. We analysed data using two categories. First, we analysed data by each medical condition across all treatment classes at two time points (immediately post-treatment and the first available follow-up). Second, we analysed data by each treatment class (cognitive behavioural therapy (CBT), family therapy (FT), problem solving therapy (PST) and multisystemic therapy (MST)) across all medical conditions at two time points (immediately post-treatment and the first available follow-up). We assessed treatment effectiveness on six possible outcomes: parent behaviour, parent mental health, child behaviour/disability, child mental health, child symptoms and family functioning.

MAIN RESULTS

Across all treatment types, psychological therapies that included parents significantly improved child symptoms for painful conditions immediately post-treatment. Across all medical conditions, cognitive behavioural therapy (CBT) significantly improved child symptoms and problem solving therapy significantly improved parent behaviour and parent mental health immediately post-treatment. There were no other effects at post-treatment or follow-up. The risk of bias of included studies is described.

AUTHORS' CONCLUSIONS

There is no evidence on the effectiveness of psychological therapies that include parents in most outcome domains of functioning, for a large number of common chronic illnesses in children. There is good evidence for the effectiveness of including parents in psychological therapies that reduce pain in children with painful conditions. There is also good evidence for the effectiveness of CBT that includes parents for improving the primary symptom complaints when available data were included from chronic illness conditions. Finally, there is good evidence for the effectiveness of problem solving therapy delivered to parents on improving parent problem solving skills and parent mental health. All effects are immediately post-treatment. There are no significant findings for any treatment effects in any condition at follow-up.

Asthma and adolescents: review of strategies to improve control

One of every 10 adolescents in the United States has asthma. Adolescents who lack asthma control are at increased risk for severe asthma episodes and death. The National Heart, Lung, and Blood Institute 2007 asthma guidelines and research studies indicated that school nurses are instrumental in assisting adolescents to monitor their asthma, learn asthma self-management skills, and improve health outcomes. This integrative review examines the research from 2005 to 2011 to identify strategies for school nurses to employ with adolescents to foster self-management skills. The research reviewed here supports the need for school nurses to engage adolescents with asthma to practice self-management behaviors. They should educate the adolescent for asthma, monitor how well the adolescent controls asthma, manage acute asthma episodes by using an asthma action plan, and coordinate care by obtaining written consent from parents to share health information with health care providers.

An intervention to increase caregiver support for asthma management in middle school-aged youth

OBJECTIVE

Asthma control requires adherence to a treatment regimen. Caregiver involvement is a key determinant of adolescent asthma control, but the involvement must recognize the youth's developmental stage and need for autonomy. This article describes the evaluation of a pilot asthma management intervention for middle school-aged youth and their adult network members, including caregivers, based on caregiver findings.

METHODS

Following approval from San Diego State University's Institutional Review Board and school district authorization, two middle schools were randomized into one of two conditions: 6-weekly group-based skills training for the adolescents followed by 6-weekly targeted newsletters for caregivers and others (Group 1) versus group-based skills training for adolescents only (Group 2). Outcome evaluation examined pre-post changes by study condition.

RESULTS

Caregivers in both groups reported improvements in quality of life (QOL) and access to asthma care resources among their adolescents. Caregiver self-efficacy increased significantly among Group 1 versus Group 2 caregivers, while Group 2 caregivers (those who did not receive newsletters) reported that their adolescents had more responsibility for their asthma care compared with Group 2 caregivers.

CONCLUSIONS

The adolescent-only intervention resulted in improvements in caregivers' QOL and parenting behaviors that promoted the adolescent's access to asthma resources. When caregivers were directed with intervention materials, their self-efficacy increased. Those who did not receive materials reported that their adolescents had more responsibility for their asthma care. The latter finding may reflect an unintended consequence of an adolescent-only intervention as it may communicate to caregivers to assume less responsibility for their child's asthma care.

Community-based approaches to controlling childhood asthma

The prevalence and burden of childhood asthma remain high and are increasing. Asthma hot spot neighborhoods around the country face particular challenges in controlling the effects of the condition. Increasing attention is being paid to developing interventions that recognize the child and family as the primary managers of disease and to introducing assistance that reaches beyond the clinical care setting into the places where families live and work. A range of types of community-focused interventions has been assessed in the past decade in schools, homes, and community health clinics, and programs using electronic media and phone links have been evaluated. Stronger evidence for all these approaches is needed. However, school-based programs and community coalitions designed to bring about policy and systems changes show particular promise for achieving sustainable improvements in asthma control. Research is needed that emphasizes comparisons among proven asthma control interventions, translation of effective approaches to new settings and communities, and institutionalization of effective strategies.

A biopsychosocial approach to asthma in adolescents encountering child protective services

OBJECTIVE

To further test the validity of the Biobehavioral Family Model (BBFM), a biopsychosocial approach to explaining the effects of family processes on illness, by testing the model with adolescents with asthma involved in child protective services (CPS), a sample for whom the model's constructs are highly relevant.

METHODS

Data are from the National Survey of Child and Adolescent Well-Being, CPS sample (n = 5,501). Adolescents with asthma (n = 101, ages 11-15 years) self-reported their negative family emotional climate (NFEC; caregiver psychological aggression and caregiver relationship quality), caregiver-adolescent relational security, and depressive symptoms. Caregivers rated adolescent health quality. Models were tested using path analyses and bootstrapping.

RESULTS

Path analyses and bootstrapping results demonstrate support for the BBFM in explaining health quality for this sample.

CONCLUSIONS

Applying the BBFM to families involved with CPS demonstrates pathways by which family processes affect health quality of adolescents with asthma, underscoring the need for biopsychosocial assessments and services.

Asthma self-management is sub-optimal in urban Hispanic and African American/black early adolescents with uncontrolled persistent asthma

INTRODUCTION

Youth as young as 11 are given responsibility to manage their asthma. Yet, little is known regarding early adolescents' asthma self-management behaviors. This study characterizes urban early adolescents' asthma self-management behaviors and perceived responsibility to manage asthma, exploring demographic differences and examining the relationship between asthma responsibility and disease management.

METHODS

About 317 Hispanic and African American/Black early adolescents (mean age = 12.71) with persistent, uncontrolled asthma reported prevention and symptom management steps, and responsibility for asthma care. We used Poisson, cumulative logistic, logistic, and linear mixed-effects regression models to assess the relationships among demographic predictors, prevention and management behaviors, and responsibility for asthma care.

RESULTS

Fifty percent took 7-9 prevention steps; few saw physicians when asymptomatic or took daily medication. When symptomatic, 92% used medication to treat symptoms and 56% sought medical attention. Controlling for asthma responsibility, fewer older youth reported observing how they feel when asthma is likely to start, observing symptom changes, or asking for help. More boys reported taking medication daily or upon trigger exposure. Controlling for age, gender, and race/ethnicity, those reporting more asthma responsibility were less likely to report taking management steps, seeking preventive care, asking for help, or going to a doctor/hospital for their asthma.

CONCLUSIONS

Early adolescents' asthma self-management is suboptimal. With increasing age, they are less observant regarding their asthma and less likely to seek help. Although they perceive themselves to have greater responsibility for managing their asthma, early adolescents do less to care for their asthma, suggesting they are being given responsibility for asthma care prematurely.

My child is diagnosed with asthma, now what?: motivating parents to help their children control asthma

Pediatric asthma is often undiagnosed, and therefore untreated. It negatively impacts children's functioning, including school attendance and performance, as well as quality of life. Schoolwide screening for asthma is becoming increasingly common, making identification of possible asthma particularly relevant for school nurses. Nurses may need to help parents cope with the new diagnosis, and teach them skills to manage the illness. The aim of this article is to present a three-phase model of how parents cope with a newly diagnosed pediatric chronic illness. Using asthma as an example, we describe these phases (Emotional Crisis, Facing Reality, and Reclaiming Life), illustrate how parents progress through the phases, and discuss situations associated with possible regression. Next, we offer strategies framed around a theory of asthma self-management to assist school nurses and other medical providers to motivate parents to develop successful disease management skills.

Knowledge, Skills, and Qualities for Effectively Facilitating an Adolescent Girls' Group

Nurses employed in a variety of school settings often rely on group-format approaches to support the health and well-being of adolescent girls. The process of selecting an effective facilitator, and evaluating the impact of a facilitator on intervention process and outcomes, is rarely described. The purpose of this article was to synthesize the literature regarding facilitator knowledge, skills, and qualities to provide school-based researchers and practitioners with a framework for selecting and evaluating group facilitators. Literature was reviewed between Fall of 2008 and Spring of 2011. Findings were synthesized into categories that provide the organization for this article (why groups, why a facilitator, and the knowledge, skills, and qualities of an effective girls' group facilitator). Nurses need to carefully identify, select, and equip those who serve as facilitators because group successes, evidenced in the ways girls grow and support each other in growth, are the result of a successful, well-matched facilitator-group participant experience.

A pilot study to enhance preventive asthma care among urban adolescents with asthma

BACKGROUND

Low-income, minority teens have disproportionately high rates of asthma morbidity and are at high risk for nonadherence to preventive medications.

OBJECTIVE

To assess the feasibility and preliminary effectiveness of an innovative school-based asthma program to enhance the delivery of preventive care for 12-15 year olds with persistent asthma. We hypothesized that this intervention would (1) be feasible and acceptable among this population and (2) yield reduced asthma morbidity.

DESIGN/METHODS

SUBJECTS/SETTING

Teens with persistent asthma and a current preventive medication prescription in Rochester, NY.

DESIGN

Single group pre-post pilot study during the 2009-2010 school year.

INTERVENTION

Teens visited the school nurse daily for 6-8 weeks at the start of the school year to receive directly observed therapy (DOT) of preventive asthma medications; 2-4 weeks following DOT initiation, they received three counseling sessions (one in-home and two via telephone) using motivational interviewing (MI) to explore attitudes about asthma management, build motivation for medication adherence, and support transition to independent preventive medication use.

PRIMARY OUTCOME

Number of symptom-free days (SFDs)/2 weeks; outcome data were collected 2 months after baseline and at the end of school year.

RESULTS

We enrolled 30 teens; 28 participated in the intervention. All teens initiated a trial of school-based DOT. All in-home MI visits were completed successfully, and 89% completed both follow-up sessions. Teens experienced an overall reduction of symptoms with more SFDs/2 weeks from baseline to 2-month and final (end of school year) assessments (8.71 vs. 10.79 vs. 12.89, respectively, p = .046 and p = .004). Teens also reported fewer days with symptoms, less activity limitation, and less rescue medication use (all p < .05). Exhaled nitric oxide levels decreased (p = .012), suggesting less airway inflammation. At the final assessment, teens reported significantly higher motivation to take their preventive medication every day (p = .043). At the end of the study, 79% of teens stated that they were better at managing asthma on their own, and 93% said they would participate in a similar program again.

CONCLUSIONS

This pilot study provides preliminary evidence of the feasibility and effectiveness of a novel school-based intervention to promote independence in asthma management and improve asthma outcomes in urban teens.

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.

Youth and Parent Versions of the Asthma-Related Anxiety Scale: Development and Initial Testing

Among adults, anxiety related to asthma has been acknowledged to influence asthma self-management. However, it has not been addressed in pediatric samples and there have been no measures developed to assess asthma-related anxiety in youth or parents. The objective of this study was to develop and test the psychometric properties of novel instruments assessing asthma-related anxiety: the Youth Asthma-Related Anxiety Scale (YAAS) and Parent Asthma-Related Anxiety Scale (PAAS). Scale items were analyzed for content validity. We determined the factor structure using exploratory factor analysis and tested the scales' psychometric properties with 285 Hispanic and African American early adolescents with uncontrolled asthma (mean age=12.8) and their parents (n=230) who participated in a larger randomized control trial testing the efficacy of an asthma intervention; control group families (134 youth and 103 parents) provided follow-up data to assess temporal stability. Both the YAAS and PAAS contained 2 factors with Cronbach alpha coefficients ranging from 0.75 to 0.90. The 2 factors, anxiety about asthma severity and about disease-related restrictions, were highly correlated within each measure. The measures displayed content and construct validity and demonstrated moderate temporal stability over 2-3 months (range: 0.36-0.42). The YAAS and PAAS have adequate psychometric properties and can meaningfully contribute to the assessment of asthma-related anxiety in adolescents and their parents, filling a clinical need in this population.

The effects of coping skills training among teens with asthma

This pilot study used a pretest and posttest design to examine the effect of a school-based intervention, Coping Skills Training, among teens with asthma (N = 39) aged 14 to 18 years randomly assigned to treatment and control groups from three midwestern high schools. Variables included asthma self-efficacy, social support, asthma-related quality of life, peak expiratory flow rate, asthma diary symptoms, and rescue medication usage. The treatment group scored significantly higher on self-efficacy (p < .001), activity-related quality of life (p = .05), and social support (p < .001) compared with the control group after using ANCOVA to adjust for baseline scores. Significant improvements were also noted from pre- to posttest in the treatment group for self-efficacy (p < .001) and quality of life (p = .02). This study indicates that Coping Skills Training is an important intervention for further study with teens with asthma.

Family support and asthma outcomes in adolescents: barriers to adherence as a mediator

PURPOSE

Asthma morbidity in children is associated with family psychosocial functioning. Although the family plays a pivotal role in maintaining optimal asthma care, the mechanism of how family support influences asthma outcomes is not well understood. The purpose of this study was to examine the role of barriers to adherence in mediating the effect of family support on asthma outcomes in adolescents.

METHODS

The sample included 126 adolescents with asthma aged 13-20 years, living in the Northeast United States. The sample consisted of 49% Whites and 51% minorities, including primarily Blacks (38%) followed by Hispanic (11%). Adolescents provided self-reported data. Structural equation modeling was performed to examine the direct and indirect relationships between family support and asthma outcomes.

RESULTS

Family support was positively associated with asthma control and quality of life. These significant associations were mediated by barriers to adherence. Particularly, family support was found to reduce barriers concerning adolescents' negative attitudes toward medication and healthcare providers, which in turn improved asthma control and quality of life symptoms, emotional functioning, and activity domains. Adolescents' cognitive difficulty also tended to mediate the relationship between family support and emotional functioning.

CONCLUSION

This study highlights the beneficial effects of family support in improving asthma outcomes in adolescents. Family support exerts the positive effect by ameliorating barriers to treatment adherence in adolescents, particularly the barriers associated with negative attitudes and cognitive challenges. The findings underscore the importance of incorporating family assessment and intervention in caring for adolescents with asthma.