Factors associated with completion of a behavioral intervention for caregivers of urban children with asthma

So what I'm stressed? A qualitative study examininga caregivers' reactions to emerging biomarkers of stress

Background

Caregivers of adults with cancer often report significant distress yet remain difficult to engage in supportive services. While the field of Psychosomatic Medicine has continued to identify important markers of physiologic stress, and demonstrated disruption in these markers in caregiver populations, no research has investigated whether biomarker information on caregivers' reaction to stress could impact their willingness to address their ongoing distress.

Methods

Here, we report on a qualitative study (N = 17) in which we conducted individual interviews with cancer caregivers to explore their key attitudes towards, and subjective experience of, mock stress biomarker data. A total of 17 caregivers of patients (M age = 56.1 years; SD = 12.3) with primarily metastatic brain tumors (glioblastoma) were interviewed regarding four commercially available biomarkers (telomere length; hair cortisol, activity levels and heart rate variability). Once presented with information about stress biomarkers, caregivers were asked to discuss their subjective reaction as if it was their own data as well as their motivation and willingness to seek support after receiving such information. We identified and extracted relevant themes.

Results

Analysis utilizing the framework method revealed four emerging themes. The first theme described caregivers' ability to manage stress and willingness to engage with supportive services. Second, caregivers generally accepted the biomarker data but preferred it to be presented in a specific way. The third theme demonstrated that for some, biomarker data may actually increase their subjective distress (e.g., whether or not something could be done to improve their mental state). The last theme described how biomarkers were generally received as meaningful motivators that could increase caregivers' willingness to engage with supportive services.

Conclusions

In addition to the more general identified theme of CG's willingness to engage with additional support, we gained insights into caregivers' reaction to the stress biomarkers presented. Findings will set the stage for the utility of stress biomarker information and whether it influences cancer caregivers' willingness to address their distress and motivation to engage in supportive services.

Psychometric evaluation of the medication adherence report scale in caregivers of low-income, urban, African American children with poorly controlled asthma

OBJECTIVE

Accurately assessing asthma medication usage among low-income, urban, African American children is essential to reduce asthma health disparities. The purpose of this study was to examine the factor structure of the five-item Medication Adherence Report Scale (MARS), in a sample of caregivers of low-income, urban, African American youth with poorly controlled asthma.

METHOD

Using baseline data from a randomized clinical trial evaluating the efficacy of an environmental control educational intervention, confirmatory factor analysis (CFA) was conducted to ascertain the MARS factor structure. Construct validity was assessed using a regression model inclusive of caregiver-reported medication adherence, Asthma Medication Ratio (AMR), asthma control, and caregiver perception of asthma control as predictors of the MARS.

RESULTS

Caregivers were female (97%) and 27.4% had an annual income under $10,000. The mean MARS score was 21.88 ± 3.33 out of a possible range of 5-25, representing high adherence. Confirmatory factor analysis indicated that a five-item one-factor model marginally fit the data based on the fit indices: χ² (5) = 31.71, p < 0.001; RMSEA ≤ 0.161; CFI = 0.986; TLI = 0.971; and WRMR = 0.979. The MARS was associated with another caregiver-reported measure of medication adherence but not associated with AMR, asthma control, or caregiver perception of asthma control.

CONCLUSIONS

The MARS demonstrated marginal fit in CFA and may not be clinically indicated in light of the lack of associations with objective measures of asthma medication adherence and asthma control.

Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children

Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.

The Chronicity of Depressive Symptoms in Mothers of Children With Asthma

Depression can disproportionately affect low-income women. The purpose of this study was to explore the chronicity of depressive symptoms in a sample of 276 low-income inner-city mothers of children with high-risk asthma. The aims were to identify factors (asthma health status, stress, social support) associated with change in depressive symptomatology over 12 months as well as to ascertain what factors are most consistently associated with depressive symptoms. Using latent growth curve analysis, demographic variables, asthma severity, stress, and social support failed to explain changes in depressive symptomatology. The growth curve models, however, were predictive of Center for Epidemiologic Studies-Depression Scale (CES-D) scores at distinct time points indicating that higher daily stress and lower social support were associated with increased depressive symptoms. Our data highlight the chronic nature of depressive symptoms in low-income mothers of children with poorly controlled asthma. Integrating questions about caregiver psychological state across all clinical encounters with the family may be indicated.

Barriers and motivators to reducing secondhand smoke exposure in African American families of head start children: a qualitative study

OBJECTIVE

To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, low-income, urban children.

METHOD

Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational-interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking.

RESULTS

African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems.

DISCUSSION

Urban, low-income African-American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members.

Participant Experiences in the Environmental Determinants of Diabetes in the Young Study: Common Reasons for Withdrawing

BACKGROUND

To characterize participant reasons for withdrawing from a diabetes focused longitudinal clinical observational trial (TEDDY) during the first three study years.

METHODS

8677 children were recruited into the TEDDY study. At participant withdrawal staff recorded any reason parents provided for withdrawal. Reasons were categorized into (1) family characteristics and (2) protocol reasons. Families who informed staff of their withdrawal were classified as active withdrawals (AW); families without a final contact were considered passive withdrawals (PW).

RESULTS

Withdrawal was highest during the first study year (n = 1220). Most families were AW (n = 1549; 73.4%). PW was more common in the United States (n = 1001; 37.8%) and among young mothers (p = 0.001). The most frequent protocol characteristic was blood draw (55%) and the most common family reason was not having enough time (66%). The blood draw was more common among female participants; being too busy was more common among males. Both reasons were associated with study satisfaction.

CONCLUSIONS

Results suggest that, for families of children genetically at risk for diabetes, procedures that can be painful/frightening should be used with caution. Study procedures must also be considered for the demands placed on participants. Study satisfaction should be regularly assessed as an indicator of risk for withdrawal.

Stress and Quality of Life in Urban Caregivers of Children With Poorly Controlled Asthma: A Longitudinal Analysis

INTRODUCTION

The intent of this analysis was to examine the longitudinal effects of risk and protective factors on quality of life (QOL) in caregivers of minority children with asthma.

METHOD

Caregivers (n = 300) reported on demographics, child asthma characteristics, daily asthma caregiving stress, general life stress, social support, and QOL. Latent growth curve modeling examined changes in QOL across 12 months as a function of stress, asthma control, and social support.

RESULTS

Caregivers were primarily the biological mother (92%), single (71%), unemployed (55%), and living in poverty. Children were African American (96%), Medicaid eligible (92%), and had poorly controlled asthma (93%). Lower QOL was associated with higher life stress, greater asthma caregiving stress, and lower asthma control over time.

DISCUSSION

Findings underscore the importance of assessing objective and subjective measures of asthma burden and daily life stress in clinical encounters with urban, low-income caregivers of children with poorly controlled asthma.

Health Characteristics of Solo Grandparent Caregivers and Single Parents: A Comparative Profile Using the Behavior Risk Factor Surveillance Survey

Objectives. To describe the health characteristics of solo grandparents raising grandchildren compared with single parents. Methods. Using the 2012 Behavioral Risk Factor Surveillance System, respondents identified as a single grandparent raising a grandchild were categorized as a solo grandparent; grandparent responses were compared with single parents. Descriptive analysis compared health characteristics of 925 solo grandparents with 7,786 single parents. Results. Compared to single parents, grandparents have a higher prevalence of physical health problems (e.g., arthritis). Both parent groups have a high prevalence of lifetime depression. A larger share of grandparents actively smoke and did no recreational physical exercise in the last month. However, grandparents appear to have better access to health services in comparison with single parents. Conclusion. Solo grandparents may be at risk for diminished physical capacity and heightened prevalence of depression. Health professionals can be an important resource to increase grandparents' physical and emotional capacities.

A Systematic Review of School-Based Alcohol and other Drug Prevention Programs

BACKGROUND

Alcohol use in adolescents constitutes a major public health concern. Europe is the heaviest drinking region of the world. Several school-based alcohol prevention programs have been developed but it is not clear whether they are really effective. The present study was aimed at identifying the typology with the best evidence of effectiveness in European studies.

METHODS

A systematic search of meta-analyses and/or randomized controlled trials (RCTs) on interventions school-based prevention programs aimed at preventing alcohol consumption or changing the attitudes to consume alcohol.

RESULTS

A meta-analysis published in 2011 and 12 RCTs more recently published were identified. The meta-analysis evaluated 53 RCTs but only 11.3% of them were conducted in Europe. Globally, 23 RCTs (43.4%) showed some evidence of effectiveness, and 30 RCTs (56.6%) did not find significant difference between the groups. According to the conclusions of the meta-analysis, the Unplugged program should be considered as a practice option in Europe. Among the other 12 RCTs, 42% were conducted in Europe. Globally, 7 studies (58.3%) achieved positive results, and 5 studies (41.7%) did not find significant differences or produced a mixed pattern of results. Three of the 5 European trials (60%) used the Unplugged program with positive results.

CONCLUSION

Even if further studies should be conducted to confirm these results, Unplugged appears to be the prevention project with the best evidence of effectiveness in European studies.

The influence of community violence and protective factors on asthma morbidity and healthcare utilization in high-risk children

We examined the longitudinal effects of community risk and protective factors on asthma morbidity and healthcare utilization. Three hundred urban caregivers of children with poorly controlled asthma were enrolled in a randomized controlled trial testing the effectiveness of a behavioral/educational intervention and completed measures of exposure to community violence (ECV), social cohesion (SC), informal social control (ISC), child asthma control, child asthma symptom days/nights, and healthcare utilization. Latent growth curve modeling examined the direct and interaction effects of ECV, SC, and ISC on the asthma outcomes over 12 months. Caregivers were primarily the biological mother (92 %), single (70 %), and poor (50 % earned less than $10,000). Children were African American (96 %) and young (mean age = 5.5 years, SD = 2.2). ECV at baseline was high, with 24.7 % of caregivers reporting more than two exposures to violence in the previous 6 months (M = 1.45, SD = 1.61). Caregiver ECV-predicted asthma-related healthcare utilization at baseline (b = 0.19, SE = 0.07, p = 0.003) and 2 months (b = 0.12, s.e. = 0.05, p = 0.04). ISC and SC moderated the effect of ECV on healthcare utilization. Our findings suggest that multifaceted interventions that include strategies to curb violence and foster feelings of cohesion among low-income urban residents may be needed to reduce asthma-related emergency services.

Improving preventive care in high risk children with asthma: lessons learned

OBJECTIVES

Rates of preventive asthma care after an asthma emergency department (ED) visit are low among inner-city children. The objective of this study was to test the efficacy of a clinician and caregiver feedback intervention (INT) on improving preventive asthma care following an asthma ED visit compared to an attention control group (CON).

METHODS

Children with persistent asthma and recent asthma ED visits (N = 300) were enrolled and randomized into a feedback intervention or an attention control group and followed for 12 months. All children received nurse visits. Data were obtained from interviews, child salivary cotinine levels and pharmacy records. Standard t-test, chi-square and multiple logistic regression tests were used to test for differences between the groups for reporting greater than or equal to two primary care provider (PCP) preventive care visits for asthma over 12 months.

RESULTS

Children were primarily male, young (3-5 years), African American and Medicaid insured. Mean ED visits over 12 months was high (2.29 visits). No difference by group was noted for attending two or more PCP visits/12 months or having an asthma action plan (AAP). Children having an AAP at baseline were almost twice as likely to attend two or more PCP visits over 12 months while controlling for asthma control, group status, child age and number of asthma ED visits.

CONCLUSIONS

A clinician and caregiver feedback intervention was unsuccessful in increasing asthma preventive care compared to an attention control group. Further research is needed to develop interventions to effectively prevent morbidity in high risk inner-city children with frequent ED utilization.

Challenges in providing preventive care to inner-city children with asthma

Although the scientific understanding of the pathophysiology of asthma and the quality of asthma therapies have significantly improved over the past 30 years, asthma morbidity remains high and preventive care low for inner-city children. This article focuses on 4 major challenges to providing preventive care (family and patient attitudes and beliefs, lack of access to quality medical care, psychosocial factors, environmental factors) based on prior evidence and the authors' observation of these challenges in research with inner-city children with asthma over the past decade. Cost issues related to preventive care are addressed, and recommendations provide for pediatric nurses.