Enhancing Asthma Self-Management in Rural School-Aged Children: A Randomized Controlled Trial

Study protocol for a randomized controlled trial of Adapt 2 Asthma (A2A), a culturally relevant coping skills and asthma management intervention for Latinx Families

BACKGROUND

Latinx children in the United States experience disparities in asthma control and asthma-related functional outcomes compared to non-Latinx White children, including more school absences, emergency department visits, and hospitalizations for asthma. Stress appears to play a role in asthma control, but interventions designed to address the role of stress in asthma control for Latinx children are limited.

METHOD

The current randomized controlled trial tests the effects of Adapt 2 Asthma (A2A), a family-based coping skills and asthma management intervention tailored to the stressors, strengths, and cultural beliefs of Latinx families, compared to an asthma self-management control arm (the Asthma Plan for Kids; APK). Latinx families of children ages 8 to 14 years old with asthma (target N = 280) are identified and enrolled from primary care clinics and randomly assigned to either A2A or APK. The intervention is delivered by lay health workers trained and receiving ongoing consultation from the study team. The primary outcome is child- and parent-reported asthma control, while secondary outcomes are child's quality of life, lung function, school absences, and emergency department visits, and child and parent coping and family asthma management behaviors. Participants will be assessed at baseline, post-intervention, and at 6- and 12-month follow-up timepoints.

DISCUSSION

This study has the potential to provide new evidence regarding the effects of culturally relevant coping and asthma management intervention strategies for Latinx children with asthma.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05118282 . Registered on 11 November 2021.

Systematic review and meta analysis of psychological interventions to prevent or treat pediatric chronic disease in rural communities

OBJECTIVE

The purpose of this systematic review and meta-analysis was to examine the effectiveness of psychological interventions at improving physical or mental health outcomes for youth living in rural communities who have, or are at-risk for, any chronic medical condition in comparison to control interventions conducted in rural communities.

METHODS

Following prospective registration (OSF.IO/7TDQJ), 7 databases were searched through July 1, 2023. Studies were included if they were a randomized control trial of a psychological intervention conducted with youth living in a rural area who had, or were at-risk for, a chronic medical condition. Risk of bias was assessed with the Cochrane risk of bias version 2 tool. A qualitative synthesis and meta-analysis were conducted.

RESULTS

15 studies met inclusion criteria. Obesity studies (n = 13) primarily focused on body mass index metrics, with limited significant findings across studies. Asthma treatment interventions (n = 2) showed no impact on hospitalizations. 3 studies evaluated mental health outcomes with no significant group differences observed. We meta-analytically analyzed 9 studies that evaluated body mass index z-scores and identified an overall null effect (Hedge's g = 0.01, 95% CI [-0.07, 0.09], p = .85).

CONCLUSIONS

Most included studies focused on pediatric obesity, and there was a limited range of health outcomes reported. Compared to controls, minimal significant improvements in health outcomes were identified for psychological interventions for youth living in rural communities. Future efforts may benefit from situating this work more systematically within a health disparities framework with a focus on understanding mechanisms of disparities and translating this work into interventions and policy changes.

Children and young people's self-reported experiences of asthma and self-management nursing strategies: An integrative review

AIM

To explore children and young people's (CYP) (5-24 years of age) self-reported experiences of asthma self-management strategies (ASMS) with nursing involvement across various settings.

BACKGROUND

Childhood asthma is an increasingly significant health issue, highlighting the importance of acquiring self-management skills to optimise future health outcomes. Registered nurses play a pivotal role in delivering appropriate, personalized self-management support.

METHODS

This integrative review searched four electronic databases: Cumulated Index to Nursing and Allied Health Literature via Elton B. Stephens Company, Medical Literature Analysis and Retrieval System Online (MEDLINE), Object, View and Interactive Design (OVID), and PubMed, that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart. Included studies were critically appraised using the Joanna Briggs Institute critical appraisal tools. Braun and Clarks thematic analysis was used to generate themes, and sub-themes.

FINDINGS

Fifteen studies were included for review. Thematic analysis generated three themes being healthy literacy; health and wellbeing; and tools and working together.

CONCLUSIONS

Asthma continues to have negative physical, psychological, and social implications among CYP. CYP are both willing and capable of engaging in ASMS and learning self-management skills, however, continue to have unmet self-management needs.

IMPLICATIONS TO PRACTICE

Strategies must bolster health literacy, improve physical and psychological health, and harness interactive, youth-centric, and informative tools to facilitate communication and decrease the burden of self-management. Applications pose a promising avenue for self-management support. This age group remains under-explored and future research should enable meaningful engagement with CYP to better understand their perspectives and improve strategy success.

Systematic review and meta-analysis of interventions to promote medication adherence among children, adolescents, and young adults with medical conditions

OBJECTIVE

This meta-analysis examined the efficacy of adherence-promotion interventions for children, adolescents, and young adults prescribed a medication for > 90 days as part of a treatment regimen for a medical condition.

METHODS

A systematic literature review was conducted to identify randomized controlled trials of adherence-promotion interventions published between 2013 and 2023 and including children, adolescents, and/or young adults with a medical condition. A total of 38 articles representing 39 trials met inclusion criteria. A narrative synthesis was conducted to summarize included trials and a random-effects model was used to compute an overall intervention effect. Effect sizes by adherence outcome assessment methodology, participant age, and technology use were also computed.

RESULTS

Pediatric adherence-promotion interventions demonstrate a medium effect with those randomized to an intervention displaying greater improvements in medication adherence than those randomized to a comparator condition (SMD = 0.46, 95% CI: 0.31, 0.60, n = 37; 95% Prediction Interval: -0.32, 1.23).

CONCLUSIONS

Adherence interventions for children, adolescents, and young adults with medical conditions increase adherence.

Effectiveness of nursing interventions for management of children with bronchial asthma: A systematic review and meta-analysis

AIM

Nursing interventions include the preventive care that can support and guide the nurse's effort to provide asthma interventions for children. Hence, this review was done to assess the effectiveness of nursing interventions for management of childhood asthma.

METHODS

We conducted a search in Medline, the Cochrane library, EMBASE, ScienceDirect and Google Scholar from 1964 until April 2022. Meta-analysis was done using a random-effects model and pooled weighted mean difference (WMD) or standardized mean difference (SMD) and/or risk ratio (RR) with 95% confidence intervals (CIs).

RESULTS

Fourteen studies were analysed. The pooled RR was 0.49 for emergency visits (95% CI: 0.32 to 0.77) and 0.46 for hospitalizations (95% CI: 0.27 to 0.79). The pooled WMD was -1.20 for number of days with symptoms (95% CI: -3.50 to 1.11), -0.98 for number of nights with symptoms (95% CI: -2.94 to 0.98) and -0.69 for frequency of asthma attacks (95% CI: -1.19 to -0.20). The pooled SMD was 0.39 for quality of life (95% CI: 0.11 to 0.66) and 0.58 for asthma control (95% CI: -0.29 to 1.46).

CONCLUSION

Nursing interventions were relatively effective in improving the quality of life and reducing asthma related emergencies, acute attacks and hospitalization amongst childhood asthma patients.

Effectiveness of Community-Based Nursing Intervention for Asthmatic Children: A Systematic Review and Meta-Analysis

Background

Preventive care can support and direct the nurse's efforts to deliver an asthma intervention for children as part of nursing interventions. Despite the significance, there have been few meta studies demonstrating the effectiveness of nursing interventions for the treatment of childhood asthma that includes only randomised controlled trials (RCTs). Therefore, this meta study was conducted to comprehensively evaluate the efficacy of nursing care interventions for the management of childhood asthma.

Methods

STATA 14.2 (StataCorp, College Station, TX, USA) was used to conduct the meta-analysis. From 1964 to July 2022, we searched Medline, the Cochrane library, EMBASE, Scopus Science Direct, and Google Scholar. Depending on the type of outcome, a meta-analysis was performed using a random-effects model, pooled weight mean difference (WMD), standardised mean difference (SMD), and/or risk ratio (RR) with stated 95 percent confidence intervals (CIs). PRISMA guidelines were followed for conducing this study.

Results

Nine studies were analysed in total. The pooled RR for emergency visits was 0.49 (95%CI: 0.32 to 0.77), for hospitalizations was 0.64 (95%CI: 0.21 to 1.89). The pooled SMD for frequency of asthma attacks was -2.88 (95%CI: -3.22 to -2.54), quality of life was 0.49 (95%CI: 0.22 to 0.75) and asthma control was 1.25 (95%CI: -0.77 to 3.28).

Conclusion

Paediatric asthma patients who received nursing interventions reported an improved quality of life and a decrease in emergencies and acute attacks due to asthma. Future RCTs should focus on uncovering the short- and long-term effects of these nursing interventions to provide optimal management and care.

Using Randomized Controlled Trials to Estimate the Effect of Community Interventions for Childhood Asthma

INTRODUCTION

The Centers for Disease Control and Prevention's Controlling Childhood Asthma and Reducing Emergencies initiative aims to prevent 500,000 emergency department (ED) visits and hospitalizations within 5 years among children with asthma through implementation of evidence-based interventions and policies. Methods are needed for calculating the anticipated effects of planned asthma programs and the estimated effects of existing asthma programs. We describe and illustrate a method of using results from randomized control trials (RCTs) to estimate changes in rates of adverse asthma events (AAEs) that result from expanding access to asthma interventions.

METHODS

We use counterfactual arguments to justify a formula for the expected number of AAEs prevented by a given intervention. This formula employs a current rate of AAEs, a measure of the increase in access to the intervention, and the rate ratio estimated in an RCT.

RESULTS

We justified a formula for estimating the effect of expanding access to asthma interventions. For example, if 20% of patients with asthma in a community with 20,540 annual asthma-related ED visits were offered asthma self-management education, ED visits would decrease by an estimated 1,643; and annual hospitalizations would decrease from 2,639 to 617.

CONCLUSION

Our method draws on the best available evidence from RCTs to estimate effects on rates of AAEs in the community of interest that result from expanding access to asthma interventions.

Effect of asthma education on health outcomes in children: a systematic review

BACKGROUND

It remains unknown whether child-oriented asthma education is associated with better health outcomes. This meta-analysis investigated the effects of asthma education on hospitalisation and emergency department and clinic visits.

METHODS

We searched the Cochrane Library, PubMed and EMBASE for relevant studies from inception to 4 July 2021, and selected studies that reported hospitalisation or emergency department or clinic visits as outcomes. The participants were only children. Two authors independently selected the studies, assessed the quality of the included studies and retrieved the data. A third senior author was engaged to resolve disagreements. Fifteen longitudinal studies were included for the systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was used as the standard of reporting (PRISMA registration ID is 284509).

FINDINGS

Compared with the control group, the asthma education group had 54% lower hospitalisation risk (95% CI 0.32 to 0.66), and 31% lower emergency department visit risk (95% CI 0.59 to 0.81). Sensitivity analysis showed that the asthma education group had a reduced clinic visit risk (risk ratio (RR)=0.80, 95% CI 0.67 to 0.97). Subgroup analysis showed that asthma education involving both children and parents/guardians was associated with fewer hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and emergency department visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education in hospitals or non-hospitals can reduce the risk of hospitalisation and emergency department visits. However, only education in the hospitals was associated with the reduction of clinical visits (RR=0.45, 95% CI 0.22 to 0.92).

INTERPRETATION

Education is effective for controlling asthma, especially for reducing hospitalisation and emergency department and clinic visits. Education involving both children and parents/guardians is more effective than that involving only children. The setting of asthma education does not impact its effect to a large extent.

Child's Illness Representation Instrument: Testing Reliability & Factor Structure Study

BACKGROUND

Researchers have determined that illness representation, including identifying the illness, understanding the cause, and knowing the risk, may influence asthma symptom management.

PURPOSE

The purpose of study was to determine reliability and factor structure for child's version of illness representation.

METHODS

A Maximum Likelihood factor analysis was used to examine reliability and factor structure of the child version of illness representation (CIR) scale. The sample included teens ages 12 to 18 from United States (N=331) with asthma.

RESULTS

The reliability was 0.79. Eight factors loaded with the most percentage of variance.

CONCLUSIONS

The perceptions of teens on the health care provider's prescribing practices may shed light on medication adherence. More research is needed to examine CIRS function in a study on medication adherence.

Meta-Analysis of Adherence Promotion Interventions in Pediatric Asthma

BACKGROUND

Youth with asthma commonly have suboptimal adherence to inhaled corticosteroids (ICS). It is critical to systematically evaluate the effectiveness of ICS adherence promotion interventions and discern which techniques are most effective.

OBJECTIVE

This study aims to (1) quantify the extent to which interventions improve ICS adherence in pediatric asthma, (2) explore differences in effect size estimates based on intervention and study characteristics, and (3) characterize the risk of bias across interventions.

METHODS

We conducted literature searches across five databases. Included studies quantitatively measured ICS adherence as an intervention outcome among youth (<18 years old) diagnosed with asthma and were published after 1997. We analyzed aggregate effect sizes and moderator variables using random-effects models and characterized risk of bias using the Cochrane Collaboration tool.

RESULTS

Thirty-three unique studies met inclusion criteria. At post-intervention, the aggregate effect size for pediatric ICS adherence promotion interventions was small but significant (n = 33, g = 0.39, 95% confidence interval [CI] = 0.24-0.54); however, the aggregate effect size at follow-up was not statistically significant (n = 6, g = 0.38, 95% CI = -0.08 to 0.83). Method of adherence measurement and intervention format were significant moderators. Most interventions had a high risk of performance bias and an unclear risk of bias in one or more domains.

CONCLUSIONS

ICS adherence promotion interventions are effective among youth with asthma. Additional longitudinal research is needed to quantify a more precise measure of intervention effectiveness over time, and moderators of intervention effectiveness should be reassessed as the literature base expands.

Predictors of lung function trajectories in population-based studies: A systematic review

Despite the growing body of evidence on lung function trajectories over the life course and their risk factors, the literature has not been systematically synthesized. Publications related to lung function trajectories were identified from PubMed, EMBASE and CINAHL databases. Two authors independently identified publications for inclusion according to predefined selection criteria. Studies that modelled lung function trajectories and reported associated exposures were included. Meta-analyses could not be conducted due to heterogeneity in the exposures and methods used to model lung function trajectories. Nine publications were eligible for inclusion of which four used group-based trajectory modelling to model lung function trajectories, while five used latent profile analysis. Studies with repeated lung function measurements over the life course identified more trajectories than others. Only one study spanning from childhood to middle age reported catch-up trajectory. The following childhood risk factors for subnormal lung function trajectories were observed in at least across two studies: low birth weight, early wheezing, asthma, allergic sensitization, eczema, allergic rhinitis, lower respiratory tract infections, family history of asthma and second-hand smoke exposure. Adult active asthma and personal cigarette smoking were observed to be associated with accelerated decline lung trajectories. Our review identified 10 risk factors associated with the growth, catch-up, reduced plateau and decline trajectories of lung function. Intervention directed at childhood asthma and infections, and tobacco smoke exposure at all ages would help promote lung health and prevent subnormal lung function trajectories.

School-based self-management interventions for asthma among primary school children: a systematic review

A Cochrane review of school-based asthma interventions (combining all ages) found improved health outcomes. Self-management skills, however, vary according to age. We assessed effectiveness of primary school-based self-management interventions and identified components associated with successful programmes in children aged 6-12 years. We updated the Cochrane search (March 2020) and included the Global Health database. Two reviewers screened, assessed risk-of-bias and extracted data. We included 23 studies (10,682 participants); four at low risk-of-bias. Twelve studies reported at least one positive result for an outcome of interest. All 12 positive studies reported parental involvement in the intervention, compared to two-thirds of ineffective studies. In 10 of the 12 positive studies, parental involvement was substantial (e.g. attending sessions; phone/video communication) rather than being provided with written information. School-based self-management intervention can improve health outcomes and substantial parental involvement in school-based programmes seemed important for positive outcomes among primary school children.

Impact of Nurse-Led Asthma Intervention on Child Health Outcomes: A Scoping Review

Given the leading role school nurses occupy within the school setting, they are often the most suited health care professionals to lead asthma programs. However, most school-based asthma programs have been conducted by researchers outside the school setting. Thus, we aim to determine what is currently known about the type of school nurse-led asthma intervention programs and their impact on children’s asthma-related outcomes. This article describes published literature on school nurse-led asthma intervention programs for the school-aged population using Arksey and O’Malley’s scoping review framework. A search strategy was developed and implemented in six electronic databases from 1980 to 2020. Results showed that school nurse-led asthma programs were predominantly educational interventions. Yet given the positive outcomes of school nurse-led asthma interventions reported across the articles reviewed, it is important to emphasize the leadership role school nurses assume in asthma programs, to promote more positive asthma-related outcomes in school children.

The Effectiveness of a Family-Based Asthma Self-Management Program in Enhancing the Asthma Health Outcomes in School-Age Children

This quasi-experimental study aimed to evaluate a family-based asthma self-management program, based on the individual and family self-management theory and the McMaster model of family functioning. Children aged 7 to 12 with uncontrolled asthma and their families were recruited from an outpatient pulmonary department of a university hospital in Thailand. Thirty-seven child-parent pairs were randomly assigned to three sessions for a period of two months of the family-based asthma self-management program, while 37 child-parent pairs were assigned to the control group. Data were collected at baseline and after implementation at two months by using the Childhood Asthma Control Questionnaire and the Pediatric Asthma Quality of Life Questionnaire, and the measurement of pulmonary function was performed using peak flow meters. Multivariate analysis of covariance (MANCOVA) was employed to analyze the mean difference between the experimental and control groups. The results indicated significant increased asthma control status, pulmonary function, and quality of life in the children from baseline to after implementation in the experimental group that participated in the family-based asthma self-management program. Significant improvement in these three asthma health outcomes was also seen in the experimental group when compared to the control group. It was seen that the family-based asthma self-management program is useful for promoting the self-management of school-age children, enabling the control of symptoms, and enhancing health outcomes regarding asthma.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

Evaluation of Daily Lives of Children and Adolescents with Celiac Disease and Nursing Approaches

The incidence of celiac disease has been increasing in recent years. Celiac disease is an autoimmune enteropathy that emerges mostly in the childhood period. This disorder is a chronic condition of the small intestine due to gluten intake in individuals with genetic predisposition. In the treatment of celiac disease, gluten-free diet therapy is applied. However, the adaptation process to the diet may create difficulties for patients. Compliance with diet is much more difficult among patients with celiac disease in childhood and adolescence than in adult patients. Children and adolescents face distinct difficulties in their homes, at school, and in their social lives. Besides following dietary treatment, children and adolescents living with celiac disease need peer support to manage their daily routines. In this article, we aimed to discuss the problems experienced by children and adolescents living with celiac disease and nursing approaches to these problems.

Examining Social Determinants of Health in Childhood Asthma Management

PURPOSE

Social determinants of health (SDoHs) influence how well a family manages children's asthma. The aim of this study was to examine the influence of SDoHs on family asthma management.

DESIGN

A cross-sectional exploratory study was conducted with 292 children in grades 2 to 5 who had current asthma and their parents to examine associations between SDoHs and the families' asthma management, quality of life, and healthcare utilization.

METHODS

Data were collected from both child and parent. Social determinants of health include the child's race/ethnic group, age, gender, and asthma severity and the family's socioeconomic status and language spoken in the home, and the school was the community-level variable. Parents and children completed asthma management and quality-of-life scales and parents reported on the children's emergency department visits and hospitalizations for asthma.

RESULTS

Worse quality of life was reported by families with lower socioeconomic status and African American children. Asthma severity was associated with parents' asthma management but not children's asthma self-management. Families who spoke Spanish at home had the lowest socioeconomic status yet performed significantly more asthma management than English-speaking families.

CONCLUSIONS

The findings highlight factors the clinical nurse specialist should address in educational interventions.

Perspectives on managing asthma and facilitators in asthma self-management among Thai school-age children: a qualitative study

Purpose

This study explored self-management in the context of asthma experiences of school-age children and the factors that facilitate asthma self-management.

Design/methodology/approach

This is qualitative research used in-depth interviews. Purposive sampling was employed to select 15 school-age children with asthma attending the outpatient pulmonary department at university hospital in Thailand. Semistructured in-depth individual interviews were conducted. which were audiotaped and transcribed verbatim. Content analysis was used to analyze the data.

Findings

Two major themes emerged from this study: (1) perspectives on managing asthma and (2) facilitators in asthma self-management. Four subthemes emerged from the first major theme related to views on managing asthma: (1) emphasizing use of an inhaler for asthma, (2) self-monitoring for symptom, (3) difficulties with the daily regimens and (4) family support on asthma self-management. Two subthemes emerged from the second major theme related to facilitators in asthma self-management: (1) confidence in performing asthma care behaviors and (2) asthma communication.

Originality/value

This study described strategies that support asthma management of children in Thailand and provided insight into factors that influence asthma self-management. Findings will inform the development of future self-management interventions for school-age children with asthma.

A School Nurse-Led Asthma Program Reduces Absences: Evaluation of Easy Breathing for Schools

OBJECTIVE

To evaluate whether school nurses can assist pediatricians in providing asthma care and reduce school absenteeism through a program called Easy Breathing for Schools (EzBfS), a 5-element school nurse-led asthma management program and the effectiveness in reducing school absenteeism.

METHODS

Fifteen public school nurses in an urban community implemented EzBfS during the 2015-16 and 2016-17 school years. Program elements included assessment of asthma risk and asthma control, asthma education, medication review, and a pediatrician communication tool. School absence for any reason was the primary outcome; absentee rates for students with asthma enrolled in the program were compared to students with asthma in the entire school population using negative binomial regression.

RESULTS

School nurses enrolled 251/2,126 students with physician-confirmed asthma (2015-16: n = 114 and 2016-17: n = 137). Sixty eight percent of participants were Latino and 25% were Black with a mean age of 8.7 ± 2.2 years. Absentee rates were higher in children with asthma compared to children without asthma (8.3% vs 7.0% absent, respectively P < .001). Students enrolled in the program experienced a 25% decrease in absentee rate after adjusting for age, sex, race/ethnicity, and school year (rate ratio = 0.75, 95% confidence interval, 0.67, 0.85) as compared to students with asthma not enrolled in the program. Participants also demonstrated improvement in inhaler technique score (P < .001). Ninety two percent of the nurses were satisfied with the program.

CONCLUSION

EzBfS, a pragmatic, nurse-led asthma management program, was successfully implemented by school nurses and significantly decreased school absences among a sample of students with asthma.

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.

School and Community-based Nurse-led Asthma Interventions for School-aged Children and Their Parents: A Systematic Literature Review

PROBLEM

Asthma is one of the most prevalent chronic diseases in the world. Lack of asthma knowledge can lead to asthma exacerbations, more emergency room visits, school absences, and decreased quality of life. This systematic review examines the effectiveness of educational intervention programs on asthma management for school-aged children and their parents beyond inpatient clinic settings.

ELIGIBILITY CRITERIA

Educational asthma interventions for school-aged children and their parents with comparison with usual asthma care and the outcome related to asthma management. Studies included were peer-reviewed and published in English within the last five years.

SAMPLE

The eight study articles were identified in ProQuest, Medline, CINAHL, and PubMed databases.

RESULTS

The review demonstrated that educational asthma interventions for children and their parents significantly improved knowledge and skills related to asthma self-management.

CONCLUSIONS

School and community-based asthma educational intervention programs are key components for good management of asthma condition. Well-planned asthma education programs are valuable and should go beyond inpatient clinic settings for promoting and maintaining health for children with asthma and their parents.

IMPLICATIONS

School nurses are well-positioned to assume a more prominent role in asthma care to improve child health and academic outcomes. School nurses have an opportunity to establish a trusting relationship that is foundational for collaborating with parents and students for better asthma management.

Feasibility study of a combined lifestyle behaviors and asthma self-management intervention for school-aged children

PURPOSE

The purpose of this study is to test the feasibility of delivering an intervention that combines healthy lifestyle behaviors related to weight management with asthma self-management, the Living Healthy with Asthma intervention, to children who have asthma.

METHODS AND DESIGN

Using a mixed design, the feasibility study of the 12-week Living Healthy with Asthma intervention was conducted with a single group of children diagnosed with asthma. Pretest and posttest data were collected on asthma-related (self-management, metered dose inhaler [MDI] skill, asthma severity, quality of life [QOL]), and healthy lifestyle variables (body mass index [BMI], dietary quality). A matched comparison sample was drawn from a separate study that tested the same asthma self-management component (single intervention) used in the feasibility study to determine if the Living Healthy with Asthma intervention worked as well as the single intervention for improving children's asthma self-management.

RESULTS

Thirteen school-aged children were enrolled in the feasibility study. There were significant reductions in BMI z-scores (P = 0.007), and improvements in vegetable servings (P = 0.03), MDI skill (P = 0.005), children's QOL (P < 0.001), and parents' QOL (P = 0.03). When comparing the feasibility group with the matched comparison group (n = 13), there were no significant differences in asthma self-management, MDI skill, or asthma severity after the interventions.

PRACTICE IMPLICATIONS

Findings supported the feasibility of implementing the combined intervention, and it was not inferior to the single intervention-which supports nurses' efforts to help families manage multiple health problems.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rural Asthma: Current Understanding of Prevalence, Patterns, and Interventions for Children and Adolescents

PURPOSE OF REVIEW

Asthma is the most common chronic illness of children and adolescents in the USA. While asthma has been understood to disproportionately affect urban dwellers, recent investigations have revealed rural pediatric asthma prevalence to be very similar to urban and to be more closely correlated with socioeconomic and environmental factors than geographic location or population density.

RECENT FINDINGS

Rural children experience factors unique to location that impact asthma development and outcomes, including housing quality, cigarette smoke exposure, and small/large-scale farming. Additionally, there are challenging barriers to appropriate asthma care that frequently are more severe for those living in rural areas, including insurance status, lack of primary care providers and pulmonary specialists, knowledge deficits (both patient and provider), and a lack of culturally tailored asthma interventions. Interventions designed to address rural pediatric asthma disparities are more likely to be successful when targeted to specific challenges, such as the use of school-based services or telemedicine to mitigate asthma care access issues. Continued research on understanding the complex interaction of specific rural environmental factors with host factors can inform future interventions designed to mitigate asthma disparities.