Asthma management by preschool children and their families: a developmental framework

Correlation of vitamin D receptor genotypes, specific IgE levels and other variables with asthma control in children

INTRODUCTION

Asthma is a common condition affecting millions of children globally. The main goal of this study is to assess factors related to asthma management, particularly atopy level and the impact of genetic variants of the vitamin D receptor (VDR) gene.

METHODS

Asthmatic children were enrolled in an outpatient respiratory clinic. Information on patients' medication adherence, medical and medication factors, and sociodemographic were gathered. Spirometry FEV1% and FVC% measurements, and the asthma control test were used to evaluate the severity of asthma, and genotyping of the VDR gene and radioallergosorbent test (RAST) were conducted. Regression analyses were conducted to evaluate variables associated with asthma control and spirometry measures.

RESULTS

A total of 313 participants (67.4% males) were recruited in the current study. The mean age was 9.37 (±3.45) years. The mean score for adherence was 4.26 (±2.52), and only 46% of the participants had controlled asthma. Forward conditional stepwise binary regression showed that low and moderate Inhaled corticosteroids (ICS) dose (OR= 0.42 (95% CI 0.20-0.90), p = 0.026; OR = 0.371 (95% CI 0.2-0.72), p = 0.003, respectively) decreased the odds of being in the controlled asthma group, while higher inhaler score (OR = 2.75 (95% CI 2.17-3.49, p < 0.001)) increased the odds of being in the controlled asthma group. However, results found no association between VDR genotype and asthma control, spirometry values or hospitalization due to asthma.

CONCLUSIONS

The results indicated that many of the asthma patients had poorly controlled asthma. Factors that were associated with poor asthma control included poor inhaler technique.

Psychometric Properties of a Measure Assessing Anxiogenic Parenting Practices in Food Allergy

Aim

Pediatric food allergy represents a significant public health burden. In order to avoid allergen consumption, adequate management requires daily vigilance and involvement from parents, frequently leading to increased parental anxiety. While specific anxiogenic parenting practices (i.e., parenting behaviors which may aid in the development and/or exacerbation of childhood anxiety) have been documented within this population, to this point, these behaviors have not been systematically measured.

Objectives

The current study aimed to develop and examine a parent-report scale designed to measure anxiogenic parenting behaviors related to food allergy.

Methods

Participants included 177 parents of children with food allergy recruited online using Amazon Mechanical Turk (mTurk). An exploratory factor analysis was conducted to determine the factor structure of the newly developed scale. Subsequently, psychometric properties (e.g., construct validity) were examined via correlational analyses.

Results

Results indicated a 24-item, 3 factor (Factor 1: Involvement in Food Allergy; Factor 2: Worry about Food Allergy; Factor 3: Autonomy Promotion) scale, which accounted for 53.11% of the total variance. The Kaiser–Meyer–Olkin measure was acceptable, KMO = 0.872 and Bartlett’s test of sphericity indicated sufficient correlations between items (χ2 (378) = 2568.95). All subscales demonstrated strong internal consistency (Involvement in Food Allergy: α = .880; Worry about Food Allergy: α = .892; Autonomy Promotion α = .796) as well as convergent and discriminant validity.

Conclusions

Results support the overall psychometric properties of the scale. Interpretations, limitations, and future directions are discussed.

Understanding the Influences Behind Parents' Asthma Decision-Making: A Qualitative Exploration of the Asthma Network of Parents with Children with Asthma

Introduction

Interventions aimed at optimizing parents’ ability to manage their children’s asthma could be strengthened by better understanding the networks that influence these parents’ choices when managing asthma. This study aimed to explore the asthma networks of parents of children with asthma—specifically to gain insights into whom parents select to be within their networks and why; how individuals within parents’ networks influence the way in which they manage their children’s asthma medications, and factors driving the development of these networks.

Methods

A qualitative research methodology utilizing semi-structured interviews with parents of children with asthma was employed to fulfil the objectives of this study.

Results

Twenty-six face-to-face interviews with parents of children with asthma were conducted, recorded, and transcribed. Transcriptions were independently coded for concepts and themes by the research team. Asthma medications was a dominant theme identified, and revealed that parents actively sought advice and support from a series of complex and multidimensional relationships with people and resources in their health network. These not only included health care professionals (HCPs) but also personal connections, lay individuals, and resources. The composition and development of these asthma networks occurred over time and were determined by several key factors: satisfaction with their HCP provider; need for information; convenience; trust and support; self-confidence in management; and parents’ perceptions of their children’s asthma severity.

Conclusions

By exploring parents’ asthma network, this study uncovers the complex relationship between HCPs, family and friends of parents of children with asthma, and provides new insight into the intimate and parallel influence they have on parent’s decision-making.

"At a loss of what to do": a qualitative analysis of parents' online discussion forums about their administration of asthma inhalers to their young children

Objective: The difficulties adults have using inhaler devices is well documented but much less is known about how parents administer inhaler devices to young children and the difficulties experienced. The purpose of this article is to explore the underlying concepts and practical issues that parents encounter in administering inhaled asthma medications to their young children.Methods: This is a qualitative study using applied thematic analysis on parental written discourses from asynchronous online discussion forums on the topic of administration and use of asthma inhaler devices to young children.Results: "At a loss of what to do" summarizes the experiences parents described when administering inhaler devices to their young children. Parents describe the problems, the situations, the emotions, the decisions, and the confusion they face. They struggle with their child's resistance and the associated conflict, describing their own and their child's distress. Results highlight the coping strategies used in administration, how parents decide whether to use coercive measures or not, their help-seeking endeavors, together with the assurance they give to themselves and others after administration.Conclusion: The online discussions highlight parents' distress, lack of preparedness, and understanding of administering inhaler devices to young children. While the prevalence of the problem cannot be estimated from our data, it illustrates a need for some healthcare professionals to review their own knowledge and skills in administration of inhaled medication to younger patients, and their provision of patient and family centered care.

Effect of depressive symptoms on asthma intervention in urban teens

BACKGROUND

The literature suggests that depression is an important comorbidity in asthma that can significantly influence disease management and quality of life (QOL).

OBJECTIVE

To study the effect of coexisting depressive symptoms on the effectiveness of self-management interventions in urban teens with asthma.

METHODS

We analyzed data from a randomized controlled trial of Puff City, a web-based, tailored asthma management intervention for urban teens, to determine whether depression modulated intervention effectiveness for asthma control and QOL outcomes. Teens and caregivers were classified as depressed based on responses collected from baseline questionnaires.

RESULT

Using logistic regression analysis, we found that a lower percentage of treatment students had indicators of uncontrolled asthma compared with controls (adjusted odds ratios <1). However, for teens depressed at baseline, QOL scores at follow-up were significantly higher in the treatment group compared with the control group for the emotions domain (adjusted relative risk, 2.08; 95% confidence interval, 1.2-3.63; P = .01; interpreted as emotional QOL for treatment students increased by a factor of 2.08 above controls). Estimates for overall QOL and symptoms QOL were borderline significant (adjusted relative risk, 1.57; 95% confidence interval, 0.93-2.63; P = .09; and adjusted relative risk, 1.72; 95% confidence interval, 0.94-3.15; P = .08; respectively). Among teens not depressed at baseline, no significant differences were observed between treatment and control groups in QOL domains at follow-up.

CONCLUSION

Our results suggest that depression modified the relationship between the effectiveness of an asthma intervention and emotional QOL in urban teens. Further assessment of self-management behavioral interventions for asthma should explore the mechanism by which depression may alter the intervention effect.

Adherence with preventive medication in childhood asthma

Suboptimal adherence with preventive medication is common and often unrecognised as a cause of poor asthma control. A number of risk factors for nonadherence have emerged from well-conducted studies. Unfortunately, patient report a physician's estimation of adherence and knowledge of these risk factors may not assist in determining whether non-adherence is a significant factor. Electronic monitoring devices are likely to be more frequently used to remind patients to take medication, as a strategy to motivate patients to maintain adherence, and a tool to evaluate adherence in subjects with poor disease control. The aim of this paper is to review non-adherence with preventive medication in childhood asthma, its impact on asthma control, methods of evaluating non-adherence, risk factors for suboptimal adherence, and strategies to enhance adherence.

Addressing asthma management challenges in a multisite, urban Head Start program

OBJECTIVE

To develop an action plan based on asthma management challenges identified by Head Start teachers in a multisite program.

DESIGN AND SAMPLE

Qualitative, participatory action research project. Three focus groups were conducted with Head Start teachers (n=14), and 1 with Center managers (n=15) in an urban Midwestern program.

MEASURES

Brief background questionnaire and semistructured focus group interview guide. Content analytic techniques were used to identify and categorize asthma management issues in transcripts of teacher focus groups. Center managers verified the findings and recommended action plan strategies to address asthma management challenges.

RESULTS

Head Start staff identified 4 common challenges: (a) undiagnosed and unreported asthma, (b) coordinating asthma care with parents, (c) medication administration issues, and (d) variability among asthma action plans. The action plan focused on (a) early identification of asthma, (b) improving coordination of asthma care with parents, (c) developing more asthma education and resources for Head Start staff and parents, and (d) developing a standardized, comprehensive Head Start asthma action plan.

CONCLUSIONS

Public health nurses can play a major role in ensuring quality care in Head Start programs by periodically identifying staff needs and developing strategies to address asthma management challenges.

Preschoolers with asthma: narratives of family functioning predict behavior problems

This study tested a model predicting behavior symptoms in preschoolers with asthma. Specifically, it examined the role that asthma severity and children's representations of family functioning may play in the development of child behavior problems in a sample of 53 low-income preschoolers. The study included parent report of asthma severity and a narrative story-stem method to assess children's representations of both general and disease-specific family processes. A regression model tested the inclusion of both types of family processes in predicting child internalizing and externalizing behavior. Disease severity and children's family narratives independently predicted children's behavior over and above the combined effects of demographic variables including child age, socioeconomic status, and family structure. Although children's narratives about general family functioning predicted children's behavior, narratives about family response to asthma symptoms did not. Findings support that both disease severity and family functioning are important considerations in understanding children's behavior problems in the context of asthma. Clinical applications of findings may include: (1) Informing family based-assessments to incorporate children's narratives, and (2) A focus on reducing asthma symptoms and strengthening family functioning to prevent or address child behavior problems.

At what age do children start taking daily asthma medicines on their own?

OBJECTIVE

Use of daily controller medications is a critical task in management of persistent asthma. Study aims were to examine (1) the association between child age and extent of daily controller-medication responsibility in a sample aged 4 to 19 years, (2) parent, child, and disease predictors of child daily controller-medication responsibility and overall daily controller-medication adherence, and (3) the association between child daily controller-medication responsibility and overall daily controller-medication adherence.

METHODS

We conducted a cross-sectional telephone survey of 351 parents of children who were prescribed daily controller medication. Children's mean age was 10.4 years; 61.5% were male, and 88.1% were white. Parents provided all data, including an estimate of the percentage of child and parent daily controller-medication responsibility. Daily controller-medication adherence was measured as parents' report of percentage of daily doses taken per doses prescribed in a typical week. We used multivariate linear regression to determine associations between parent race/ethnicity, education, income, number of dependents, child age, gender, years since diagnosis, parent perception of symptom severity and control, and dependent variables (child daily controller-medication responsibility and daily controller-medication adherence). We also examined associations between child daily controller-medication responsibility and daily controller-medication adherence.

RESULTS

Child daily controller-medication responsibility increased with age. By age 7, children had assumed, on average, almost 20% of daily controller-medication responsibility; by age 11, approximately 50%; by age 15, 75%; and by age 19, 100%. In multivariate models, child age and male gender remained significantly associated with child daily controller-medication responsibility, and child's age and parents' race/ethnicity remained significantly associated with daily controller-medication adherence.

CONCLUSIONS

Clinicians may need to screen for child daily controller-medication management and include even young children when educating families on the use of asthma medications and other key asthma-management tasks.

'The apple doesn't fall far from the tree': the role of parents in chronic disease self-management

Medical nonadherence has been termed the "Achilles' heel of modern healthcare." In considering the need to improve medical adherence among chronically ill children, it is necessary to understand parent adherence. Parents have long been acknowledged to be the primary socialization agents in children's development across the various domains of functioning. Through communication of their beliefs, the behavior they model, and direct training, parents exert a powerful influence on the development of children's beliefs and behavior. Adherence may be similarly conceptualized as a socialization process, in which parents influence the development of children's beliefs and behavior regarding their eventual disease self-management. Given this perspective, it is important for clinicians to emphasize the need for parental adherence to a child's treatment regimen. An increased focus on parental adherence will require an investment of time and effort that will pay dividends in the long term.

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

Background

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

Methods

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

Results

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

Conclusion

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

The lived experience of fathers who have children with asthma: a phenomenological study

Asthma is a common chronic illness of childhood and a major cause of school absenteeism and hospitalization. When a child is diagnosed with asthma, parents become responsible for the long-term management of a chronic condition that is characterized by unpredictable and irregular episodes. Much of the research concerning parenting children who have asthma had focused on mothers. Paternal experiences in caring for a child with asthma have received little attention. In this phenomenological study, van Manen's (Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. The Althouse Press: London, ON) method of inquiry was used to explore the lived experience of fathers who have children with asthma. Eight fathers with children aged between 7 and 11 years who had been diagnosed with asthma were interviewed. Five themes were identified: feeling relief in knowing the diagnosis, learning the ropes, being vigilant, living with concern, and being comfortable with asthma management. Understanding the experience of fathers who have children with asthma and gaining insight into their needs and concerns are essential first steps to providing supportive nursing care.

Demands and resources: parents of school-age children with asthma

Asthma is one of the most common chronic diseases in children and is frequently noted as the reason for school absences. The purpose of this pilot study was to determine the differences in demands and resources reported by African American (AA) and European American (EA) parents of school-age children with asthma. A convenience sample of 37 parents participated in the study. Data were collected from 19 AA and 18 EA parents. Family stress theory provided the framework for this study. All subjects completed a demographic questionnaire, the Care of My Child With Asthma Scale, and the Family Inventory of Resources for Management (FIRM). Descriptive statistics were used to analyze the data. The most time-consuming caregiving demand reported by EA parents was providing emotional support for the child. For AA parents, the most time-consuming caregiving demand was managing work or school outside the home and organizing asthma treatments at the same time. AA parents had limited resources in the area of extended family social support. The Mann-Whitney U test found no statistically significant differences between AA and EA parents in relation to demands and resources. Nursing implications are presented.

Adherence in young children with asthma

PURPOSE OF REVIEW

To discuss the unique challenges of managing asthma in young children and to review the literature over the past year with regard to regimen adherence in this relatively understudied population.

RECENT FINDINGS

Young children and their families face unique challenges in dealing with asthma and these have the potential to affect regimen adherence. They include the time and effort required by asthma-management activities (e.g. nebulizer use), dependency on parents for asthma care, and the limited ability of children to communicate about their symptoms. Five published studies were found for the past year. They covered three areas: adherence assessment (e.g. electronic monitoring versus diary cards), device impact on adherence (e.g. influence of the novelty of medication-delivery device), and adherence interventions (e.g. parental education regarding symptoms).

SUMMARY

Research suggests that several components need to be considered when designing interventions to improve adherence for young children with asthma: to consider the strain in the caregiver role when developing the treatment regimen, to provide devices that parents and children can use, to monitor adherence with electronic monitoring, and to address parents' concerns and perceptions about treating prodromal symptoms of an asthma exacerbation. Because many parents are hesitant to treat cough symptoms, an additional training component may need to be added to address this concern.

Beliefs and self-care practices of adolescents with asthma

The purpose of this qualitative pilot study was to identify beliefs and self-care practices of adolescents with asthma in a private high school, where the incidence of asthma is nearly 20%. Analysis of the data from 10 individual audiotaped interviews, using a semistructured questionnaire, yielded major themes of knowledge acquisition, self-efficacy, and social support that are associated with behaviors that control asthma with better outcomes. Specifically, the greatest knowledge acquisition and symptom recognition were associated with exposure to multiple educators, especially school-based programs. High self-efficacy was facilitated through positive experiences--teens recognized that they had fewer asthma events and severity once they were in better physical condition, on preventive medicines, and/or used trigger avoidance success. Social support for teens was very helpful and included parents, family, friends, coaches and teachers, and healthcare providers. Implications for practice include the need for adolescent asthma-awareness training, as higher awareness of asthma conditions and triggers may provide peer support for teens with asthma in school.

Do children with asthma and their parents agree on household ETS exposure? Implications for asthma management

The adverse consequences of passive smoking have spurred efforts to reduce environmental tobacco smoke (ETS) exposure among children, particularly in the home. For children with asthma, teaching them to avoid tobacco smoke at home is an important element of patient self-management. This strategy assumes that children can accurately assess household smoking behaviors and the level of their own exposure in the home. This study compared child and parental assessments of household smoking behaviors in an urban, low-income and largely ethnic minority sample of asthmatic children and their parents. While there was general parent-child agreement on the smoking status of household members, there was less agreement on duration of household smoking and the child's exposure to ETS. Objective validation measures (cotinine, nicotine) suggest that parents were better able than their children to assess hours of indoor smoking. Children's assessment of the extent of exposure to ETS may be problematic, with important implications for asthma patient self-management efforts.

Transfer of asthma management responsibility from parents to their school-age children

This study used grounded theory to explore the process of transfer of responsibility for asthma management from parents to their school-age children. Interviews were conducted with 11 mothers, 2 fathers, 1 grandmother, and their 14 children who were between 8 and 13 years old. Responses revealed that transfer of responsibility within families is a complex, uneven process that occurs over years and involves identifiable stages and transitions. The Theoretical Model for Parent-Child Transfer of Asthma Responsibility emerged from the data. The central concept underlying the process was controlling the situation. Specific cues stimulated changes in parent-child responsibility.

Adherence to asthma therapy in the preschool child

Preschool children's adherence to asthma therapy is often sub-optimal and can result in decreased quality of life for children and parents, as well as an increased risk for dangerous asthma exacerbations. Asthma management for the preschool child presents some unique challenges to adherence to therapy, including the child's limited ability to communicate, multiple caregivers responsible for medications, and parental concerns about medications. Parent beliefs, characteristics of the regimen, and family functioning have been associated with adherence levels. Understanding and improving adherence to asthma therapy for the preschool child will necessarily require addressing these age-specific concerns.

Enhancing medication adherence among inner-city children with asthma: results from pilot studies

Despite the availability of effective treatments that aid in controlling asthma symptoms, inner-city children with asthma have high rates of morbidity and are frequent users of emergency department services. The goal of these studies was to pilot test an intervention that used social learning strategies (e.g., goal-setting, monitoring, feedback, reinforcement, and enhanced self-efficacy) and targeted known barriers to individualize a family-based asthma action plan. Participants were 15 children with asthma, aged 7-12 years, who had been prescribed at least one daily inhaled steroid. The children and their mothers lived in inner-city Baltimore and all were African-American. Participants received up to five visits in their home by a nurse. Electronic monitors were installed on the children's MDI to provide immediate feedback on medication adherence to the families and validate medication use. At baseline, only 28.6% of the children were using their medications as prescribed. Within four weeks, the number of children who were using their medications appropriately doubled from 28.6% at baseline to 54.1% (90% increase; p = 0.004), while underutilization decreased from 51.2% to 25.4% (100% decrease; p = 0.02). The number of children with no medication use at all dropped from 28.3% at baseline to 15.1% by week 5 (87% decrease; p = 0.009). Thus, within four weeks, more than half the children were using their inhaled steroids appropriately. In addition, the rate of underutilization decreased and that of nonutilization was cut in half. Our initial data suggest that an individualized, home-based intervention can significantly enhance adherence to the daily use of inhaled steroids in inner-city children with asthma. Nevertheless, adherence to daily inhaled steroid therapy remains a significant problem in this group.

Well-being of parents of young children with asthma

The relationships of family demands, caregiving demands, sense of coherence (SOC), and family hardiness (FH) with parents' well-being was evaluated in 76 families (75 mothers and 62 fathers) of young children (infant to 6 years) with asthma. The Resiliency Model of Family Stress, Adjustment and Adaptation (McCubbin, M., & McCubbin, 1993, 1996) was the conceptual framework for the study. The major hypothesis was that SOC and FH, separately and in combination, moderate both family system and caregiving demands on general well-being. With hierarchical regression analysis, SOC and FH explained 56% of the variance in mothers' well-being; family demands, SOC, and FH explained 67% of the variance in fathers' well-being. No moderating relationships were found for SOC or FH. Resiliency factors (SOC and FH) and family demands had direct relationships to the well-being of parents of young children with asthma.

Factors associated with medication self-administration in children with asthma

This study investigated factors associated with early self-administration of inhaled asthma medications by minority children. Specifically, the study evaluated: (1) the reasons parents allow early administration of inhaled medications, (2) childhood activities associated with early medication administration, (3) parent's perception of the child's ability to use a metered-dose inhaler (MDI), (4) the child's actual ability to use an MDI, and (5) concordance/discordance between physician-parent reports and parent-child reports of asthma medications. Study results indicated that 93% of the children were taking inhaled asthma medications without adult supervision. Early self-administration of asthma medications was related to the parent's employment status and the performance of other childhood behaviors such as completion of homework independently and crossing the street alone. Only 7% of the children had effective MDI skills, but 60% of the parents rated their child's MDI skills as excellent. Twenty percent, 67%, and 50%, respectively, of the parents' reports of beta-agonists, daily inhaled steroids, and cromolyn were discordant with the physician's actual prescriptions. Sixty-two percent, 57%, and 79%, respectively, of the children's reports for inhaled beta-agonists, daily inhaled steroids, and cromolyn were discordant with their parents' reports. Implications for anticipatory guidance, future educational strategies, and supervision of MDI technique are provided.

The allocation of family responsibility for asthma management tasks in African-American adolescents

The allocation of responsibilities for asthma management within African-American families was examined in 60 adolescents and their primary caretakers. Separate structured interviews were conducted with adolescents and primary caretakers, and perceptions of family management, adherence to asthma treatment regimen, and functional morbidity were assessed. Support for the primary hypothesis that higher levels of nonadherence and functional morbidity would be observed in families where caretakers overestimated the level of adolescent involvement in asthma self-care was found. Implications for family-based asthma management in ethnic minority adolescents are discussed.

Planning an integrated population-based program

Social, economic, and political pressures demand that hospitals focus on ways to provide cost-effective, population-based care. As a member of the hospital executive staff, nurse administrators need to have a method for analyzing, planning, implementing, and evaluating prospective programs and be able to articulate their potential and relative worth in terms of cost, quality, and value. The author presents a template model for integrated population-based program planning. Children's Home-Based Asthma Management and Prevention Service (CHAMPS) is presented to illustrate application of the model.