An education intervention for childhood asthma by Aboriginal and Torres Strait Islander health workers: a randomised controlled trial

Chronic respiratory disease in Indigenous peoples: a framework to address inequity and strengthen respiratory health and health care globally

Indigenous peoples around the world bear a disproportionate burden of chronic respiratory diseases, which are associated with increased risks of morbidity and mortality. Despite the imperative to address global inequity, research focused on strengthening respiratory health in Indigenous peoples is lacking, particularly in low-income and middle-income countries. Drivers of the increased rates and severity of chronic respiratory diseases in Indigenous peoples include a high prevalence of risk factors (eg, prematurity, low birthweight, poor nutrition, air pollution, high burden of infections, and poverty) and poor access to appropriate diagnosis and care, which might be linked to colonisation and historical and current systemic racism. Efforts to tackle this disproportionate burden of chronic respiratory diseases must include both global approaches to address contributing factors, including decolonisation of health care and research, and local approaches, co-designed with Indigenous people, to ensure the provision of culturally strengthened care with more equitable prioritisation of resources. Here, we review evidence on the burden of chronic respiratory diseases in Indigenous peoples globally, summarise factors that underlie health disparities between Indigenous and non-Indigenous people, propose a framework of approaches to improve the respiratory health of Indigenous peoples, and outline future directions for clinical care and research.

Health-related quality of life measures used with Indigenous children/youth in the Pacific Rim: a scoping review

OBJECTIVE

To identify and describe (1) which health-related quality of life (HRQoL) measures have been used with Indigenous children/youth (aged 8-17 years) within the Pacific Rim; and (2) studies that refer to Indigenous health concepts in the use of child/youth HRQoL measures.

DESIGN

A scoping review.

DATA SOURCES

Ovid (Medline), PubMed, Scopus, Web of Science and CINAHL were searched up until 25 June 2020.

ELIGIBILITY CRITERIA

Eligible papers were identified by two independent reviewers. Eligible papers were written in English, published between January 1990 and June 2020 and included an HRQoL measure used in research with Indigenous child/youth populations (aged between 8 and 17 years) in the Pacific Rim region.

DATA EXTRACTION AND SYNTHESIS

Data extracted included study characteristics (year, country, Indigenous population, Indigenous sample size, age group), HRQoL measure characteristics (generic or condition-specific measure, child or adult measure, who completed the measure(s), dimensions, items and response scale of measure) and consideration of Indigenous concepts (created for Indigenous population, modified for Indigenous population, validated for Indigenous population, reliability in Indigenous populations, Indigenous involvement, reference to Indigenous theories/models/frameworks).

RESULTS

After removing duplicates, 1393 paper titles and abstracts were screened, and 543 had full-text review for eligibility. Of these, 40 full-text papers were eligible, reporting on 32 unique studies. Twenty-nine HRQoL measures were used across eight countries. Thirty-three papers did not acknowledge Indigenous concepts of health, and only two measures were specifically created for use with Indigenous populations.

CONCLUSIONS

There is a paucity of research investigating HRQoL measures used with Indigenous children/youth and a lack of involvement of Indigenous peoples in the development and use of HRQoL measures. We strongly recommend explicit consideration of Indigenous concepts when developing, validating, assessing and using HRQoL measures with Indigenous populations.

Exploring the Reported Strengths and Limitations of Aboriginal and Torres Strait Islander Health Research: A Narrative Review of Intervention Studies

High quality intervention research is needed to inform evidence-based practice and policy for Aboriginal and Torres Strait Islander communities. We searched for studies published from 2008-2020 in the PubMed database. A narrative review of intervention literature was conducted, where we identified researcher reported strengths and limitations of their research practice. A total of 240 studies met inclusion criteria which were categorised as evaluations, trials, pilot interventions or implementation studies. Reported strengths included community engagement and partnerships; sample qualities; Aboriginal and Torres Strait Islander involvement in research; culturally appropriate and safe research practice; capacity building efforts; providing resources or reducing costs for services and communities; understanding local culture and context; and appropriate timelines for completion. Reported limitations included difficulties achieving the target sample size; inadequate time; insufficient funding and resources; limited capacity of health workers and services; and inadequate community involvement and communication issues. This review highlights that community consultation and leadership coupled with appropriate time and funding, enables Aboriginal and Torres Strait Islander health intervention research to be conducted. These factors can enable effective intervention research, and consequently can help improve health and wellbeing outcomes for Aboriginal and Torres Strait Islander people.

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services

BACKGROUND

Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches.

OBJECTIVES

To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes.

MAIN RESULTS

We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Efficacy and feasibility of the BREATHE asthma intervention with American Indian children: a randomized controlled trial

American Indian (AI) children experience significant disparities in asthma prevalence, severity, and burden of disease, yet few asthma education interventions are tested in this population. This study aimed to evaluate the efficacy and feasibility of the BREATHE intervention with parents and AI children, during a 3-year follow-up period (n = 108), using a randomized controlled design. Children with asthma identified by electronic medical records (EMR) were screened and matched with 2 controls. The intervention included an initial educational and 24 months of follow-up. The control group continued their usual care. The primary outcome was the frequency of EMR documented, emergency department (ED) visits or hospitalization for respiratory complaints. There was no statistical difference in mean primary outcomes (1.34 (1.98) vs 1.22 (1.95), - 0.88 to 0.63, 95% CI of the difference, p = 0.75), nor percent with any ED visit or hospitalization (29/53, 55% vs 30/55, 54%, p = 0.99) between the intervention or control groups respectively. After 365 days, there was a borderline significant difference in time to primary outcome. Although limited in power, the present study did not demonstrate a persistent effect of this intervention. We recommend that AI pediatric asthma interventions are culturally-designed, use feasible procedures, and repeat education at least every 12 months.

Yarning about foot care: evaluation of a foot care service for Aboriginal and Torres Strait Islander Peoples

Background

Aboriginal and Torres Strait Islander Peoples have high rates of diabetes-related foot disease including foot ulcer and amputation. There has been limited evaluation of foot care services for Aboriginal and Torres Strait Islander Peoples. This project aimed to evaluate an Aboriginal and Torres Strait Islander foot care service (the Buridja Clinic) for prevention and management of diabetes-related foot disease embedded in a university podiatry program from a Community perspective using culturally appropriate methods.

Methods

This mixed-methods study took place from March 2018 to April 2021 in the Buridja Clinic on the Central Coast of New South Wales, Australia, and included an audit of occasions of service (March 2018 to March 2020), and review of the Buridja Clinic via research yarns with Aboriginal and Torres Strait Islander clients of the clinic and a written 10-item customised clinic feedback survey. Research yarns were transcribed and analysed thematically. Descriptive analysis of quantitative occasions of use and survey data was undertaken, with the open-ended survey responses thematically analysed.

Results

Total occasions of service across the review period was 548, with a total of 199 individual clients treated. Most common service types were general treatments (nail and skin care) and diabetes assessments. Nine participants who attended the Buridja Clinic were recruited to the two research yarns. An additional 52 participants who attended the clinic completed the customised clinic feedback survey. Specific clinic design elements, including yarning circles and group booking as well as student placement, were identified as strengths of the clinic. Participants reported difficulty with transport and restricted opening hours and encouraged increased Community engagement by clinic staff.

Conclusion

Evaluation of a foot care service for Aboriginal and Torres Strait Islander Peoples embedded in a university-based podiatry program demonstrated that the incorporation of specific service design elements, including yarning circles and group appointments as well as student placements, encouraged ongoing Community engagement with the service. Participants reported improved foot health, greater foot and self-care knowledge, and overall better general health and management as a result of attendance to the clinic. Consideration needs to be given to addressing limited access to transport and flexible operating hours when establishing similar services.

Graphical abstract

Artist Jenni McEwen (Bundjalung) lives on Darkinjung Country. The story of her art shows people sitting in yarning circles sharing knowledges but looking outwards to connect with Country too, the Ochre of Wiradjuri Country around Wellington, and the Blue of Darkinjung Country around Central Coast. These are locations where podiatry service provision takes place. These are locations where everyone is sharing and learning. Students, teachers, patients, non-Indigenous people, and First Nations people, learning from each other, and learning from Country.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00524-9.

Community-based interventions for childhood asthma using comprehensive approaches: a systematic review and meta-analysis

Objective

We conducted a systematic review and meta-analysis to determine the effectiveness of comprehensive community-based interventions with ≥ 2 components in improving asthma outcomes in children.

Methods

A systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Cochrane Library and hand search of reference collections were conducted to identify any research articles published in English between 2000 and 2019. All studies reporting community-based asthma interventions with ≥ 2 components (e.g., asthma self-management education, home environmental assessment or care coordination etc.) for children aged ≤ 18 years were included. Meta-analyses were performed using random-effects model to estimate pooled odds ratio (OR) with 95% confidence intervals (CIs).

Results

Of the 2352 studies identified, 21 studies were included in the final analysis: 19 pre-post interventions, one randomised controlled trial (RCT) and one retrospective study. Comprehensive asthma programs with multicomponent interventions were associated with significant reduction in asthma-related Emergency Department (ED) visits (OR = 0.26; 95% CI 0.20–0.35), hospitalizations (OR = 0.24; 95% CI 0.15–0.38), number of days (mean difference = − 2.58; 95% CI − 3.00 to − 2.17) and nights with asthma symptoms (mean difference = − 2.14; 95% CI − 2.94 to − 1.34), use of short-acting asthma medications/bronchodilators (BD) (OR = 0.28; 95% CI 0.16–0.51), and increase use of asthma action plan (AAP) (OR = 8.87; 95% CI 3.85–20.45).

Conclusion

Community-based asthma care using more comprehensive approaches may improve childhood asthma management and reduce asthma related health care utilization.

Interventions to improve health literacy among Aboriginal and Torres Strait Islander Peoples: a systematic review

Background

Aboriginal and Torres Strait Islander peoples continue to experience poorer health outcomes than other population groups. While data specific to Indigenous Australians are scarce, a known social health literacy gradient exists linking low health literacy and poor health outcomes within many minority populations. Improving health literacy among Indigenous Australians is an important way to support self-determination and autonomy in both individuals and communities, by enhancing knowledge and improving health outcomes. This review aims to rigorously examine the effectiveness of health literacy interventions targeting Aboriginal and Torres Strait Islander peoples.

Methods

A systematic review across six databases (The Cochrane Library, PubMed, Embase, SCOPUS, ProQuest Dissertation and Thesis and Web of Science) was performed for publications evaluating interventions to improve health literacy among Indigenous Australian adults using search terms identifying a range of related outcomes.

Results

Of 824 articles retrieved, a total of five studies met the eligibility criteria and were included in this review. The included studies evaluated the implementation of workshops, structured exercise classes and the provision of discounted fruit and vegetables to improve nutrition, modify risk factors for chronic diseases, and improve oral health literacy. All interventions reported statistically significant improvement in at least one measured outcome. However, there was limited involvement of the Aboriginal and Torres Strait Islander community members in the research process and participant retention rates were sub-optimal.

Conclusion

There is limited evidence on interventions to improve health literacy in Indigenous Australian adults. Participation in interventions was often suboptimal and loss to follow-up was high. Future studies co-designed with Aboriginal and Torres Strait Islander community members are needed to improve health literacy in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10278-x.

Effects of caregiver-involved interventions on the quality of life of children and adolescents with chronic conditions and their caregivers: a systematic review and meta-analysis

PURPOSE

Childhood chronic conditions have a considerable effect on the quality of life (QoL) of pediatric patients and their caregivers. The purpose of this meta-analysis was to evaluate the effects of caregiver-involved interventions on the QoL of children and adolescents with chronic conditions and their caregivers.

METHODS

The PubMed, EMBASE, Web of Science, Cumulative Index of Nursing and Allied Health Literature, Academic Search Complete, Education Resource Information Center, and PsycINFO databases were searched for published randomized controlled trials from inception to April 2016. Two reviewers (NS and JM) independently screened included studies and assessed study quality. The meta-analyses and meta-regressions using random-effects models were performed with the Comprehensive Meta-analysis software (version 3, Biostat, Englewood, NJ).

RESULTS

Fifty-four studies involving 10075 pediatric patients diagnosed with asthma, diabetes, cancer, hypersensitivity, cerebral palsy, arthritis, or sickle cell diseases and 10015 caregivers were included in our analysis. The interventions mainly involved education about disease, skill training, environment change, psychological intervention, physical exercise, experience sharing, monitoring, or social support. The results demonstrated that caregiver-involved interventions significantly improved the health-related QoL (HRQoL) of caregivers [standardized mean difference (SMD) = 0.26, 95% CI 0.14-0.38, p < 0.001], particularly those delivered through the face-to-face mode (SMD = 0.32, 95% CI 0.21-0.43, p < 0.001). However, no improvements in the QoL (SMD = 0.00, 95% CI - 0.22 to 0.22, p = 1.00) and HRQoL (SMD = 0.06, 95% CI - 0.02 to 0.14, p = 0.16) of children and both caregivers and children (SMD = 0.04, 95% CI - 0.08 to 0.17, p = 0.52) were observed.

CONCLUSIONS

This meta-analysis provides evidence on the positive effects of caregiver-involved interventions on the HRQoL of caregivers. Moreover, face-to-face mode is the delivery approach with a promising effect on the HRQoL of caregivers. Further research on conditions not found in this review is warranted.

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

Background

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

Objectives

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

Design

Systematic review with meta-analysis.

Population

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

Intervention

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

Comparator

Usual care.

Outcomes

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

Design

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

Data sources

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

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

Culture-specific programs for children and adults from minority groups who have asthma

BACKGROUND

People with asthma who come from minority groups often have poorer asthma outcomes, including more acute asthma-related doctor visits for flare-ups. Various programmes used to educate and empower people with asthma have previously been shown to improve certain asthma outcomes (e.g. adherence outcomes, asthma knowledge scores in children and parents, and cost-effectiveness). Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual, and not just the symptoms of the disease. Therefore, questions about whether tailoring asthma education programmes that are culturally specific for people from minority groups are effective at improving asthma-related outcomes, that are feasible and cost-effective need to be answered.

OBJECTIVES

To determine whether culture-specific asthma education programmes, in comparison to generic asthma education programmes or usual care, improve asthma-related outcomes in children and adults with asthma who belong to minority groups.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, Embase, review articles and reference lists of relevant articles. The latest search fully incorporated into the review was performed in June 2016.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups with asthma.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected, extracted and assessed the data for inclusion. We contacted study authors for further information if required.

MAIN RESULTS

In this review update, an additional three studies and 220 participants were added. A total of seven RCTs (two in adults, four in children, one in both children and adults) with 837 participants (aged from one to 63 years) with asthma from ethnic minority groups were eligible for inclusion in this review. The methodological quality of studies ranged from very low to low. For our primary outcome (asthma exacerbations during follow-up), the quality of evidence was low for all outcomes. In adults, use of a culture-specific programme, compared to generic programmes or usual care did not significantly reduce the number of participants from two studies with 294 participants for: exacerbations with one or more exacerbations during follow-up (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.50 to 1.26), hospitalisations over 12 months (OR 0.83, 95% CI 0.31 to 2.22) and exacerbations requiring oral corticosteroids (OR 0.97, 95% CI 0.55 to 1.73). However, use of a culture-specific programme, improved asthma quality of life scores in 280 adults from two studies (mean difference (MD) 0.26, 95% CI 0.17 to 0.36) (although the MD was less then the minimal important difference for the score). In children, use of a culture-specific programme was superior to generic programmes or usual care in reducing severe asthma exacerbations requiring hospitalisation in two studies with 305 children (rate ratio 0.48, 95% CI 0.24 to 0.95), asthma control in one study with 62 children and QoL in three studies with 213 children, but not for the number of exacerbations during follow-up (OR 1.55, 95% CI 0.66 to 3.66) or the number of exacerbations (MD 0.18, 95% CI -0.25 to 0.62) among 100 children from two studies.

AUTHORS' CONCLUSIONS

The available evidence showed that culture-specific education programmes for adults and children from minority groups are likely effective in improving asthma-related outcomes. This review was limited by few studies and evidence of very low to low quality. Not all asthma-related outcomes improved with culture-specific programs for both adults and children. Nevertheless, while modified culture-specific education programs are usually more time intensive, the findings of this review suggest using culture-specific asthma education programmes for children and adults from minority groups. However, more robust RCTs are needed to further strengthen the quality of evidence and determine the cost-effectiveness of culture-specific programs.

Lay-led and peer support interventions for adolescents with asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

A systematic review of health service interventions to reduce use of unplanned health care in rural areas

RATIONALE, AIMS AND OBJECTIVES

Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations.

METHODS

The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively.

RESULTS

A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions.

CONCLUSION

Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results.

Carers' perspectives on an effective Indigenous health model for childhood asthma in the Torres Strait

OBJECTIVE

To describe parents'/carers' views of the characteristics of a clinical service model shown to improve asthma outcomes.

DESIGN

A randomised controlled study on education intervention for childhood asthma by Indigenous health care workers.

SETTING

Thursday Island, Horn Island and Bamaga.

PARTICIPANTS

Thirty-five children received the intervention and 53 were in the control group. At the last study visit 12 months after enrolment, carers were asked to give feedback about the clinical service delivered by paediatric respiratory physicians and the asthma education intervention.

INTERVENTION

Additional asthma education.

MAIN OUTCOME MEASURES

Carers' responses to the open-ended questions were analysed separately by three Indigenous investigators who assigned codes and developed the themes. These were then cross-checked and combined to develop an overall interpretation of the data.

RESULTS

The carers (n = 81) of 88 children in the Torres Strait region of North Queensland reported positively to the clinical service delivery. Service was rated as excellent = 26.8%, very good = 51.2%, good = 19.5% and poor = 2.4%. Parents'/carers' views about the clinical service model were grouped into seven themes: clear communication by health professionals, service delivery, professional approach, clear transfer of knowledge and education/clinical knowledge of asthma, established rapport/caregiver satisfaction, importance of coming into the local community, and areas of concern for the carers/parents.

CONCLUSION

Community-based perspectives of an effective health service model include empowered Indigenous health care workers currently attached to the medical specialist service with elements of high expertise and appropriate cultural awareness that enabled clear communication and transfer of knowledge.

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

ISSUE

Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation.

APPROACH

The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people's participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data.

KEY FINDINGS

Facilitators enabling Indigenous people's participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems.

IMPLICATION

The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Retrospective review of 200 children hospitalised with acute asthma. Identification of intervention points: a single centre study

AIM

Indigenous Australians with asthma have higher morbidity and mortality compared with non-Indigenous Australians. In children hospitalised with acute asthma, we aimed to (i) determine if acute severity, risk factors and management differed between Indigenous and non-Indigenous children; and (ii) identify intervention points to reduce morbidity and mortality of asthma.

METHODS

Retrospective review of 200 children hospitalised to Royal Darwin Hospital with asthma. We compared admission characteristics, severity indices, treatment, discharge plans and readmissions in Indigenous and non-Indigenous children.

RESULTS

Median age was 3.6 years (interquartile range 2.2, 6.8). A significantly higher proportion of Indigenous children (95.2%) were exposed to tobacco smoke compared with non-Indigenous children (45.7%). The difference in proportions was -0.41 (95% confidence interval (CI) -0.60, -0.22). Other risk factors, asthma severity (moderate 83.9% vs. 83.3%; severe 16% vs. 16.1%), length of stay (1.9 vs. 1.3 days) and readmission rate (27.4% vs. 27.5%) were similar between Indigenous and non-Indigenous children. Indigenous children were significantly more likely to be followed up in a community clinic (difference in proportions = 0.10, 95% CI 0.1, 0.17) and less likely by a paediatrician. Only 62.5% of all children had an asthma action plan on discharge.

CONCLUSION

Unlike other common respiratory diseases requiring hospitalisation, biological factors are unlikely major contributors to the known gap in asthma outcomes between Indigenous and non-Indigenous children. Intervention points include better identification, documentation and management of tobacco smoke exposure, delivery of salbutamol and discharge planning (including education and utilisation of asthma action plans).

The interplay between diet and emerging allergy: what can we learn from Indigenous Australians?

The pathophysiology of atopic diseases, including asthma and allergy, is the result of complex gene-environment interactions. Since European colonization the Indigenous population of Australia has undergone significant changes with respect to their lifestyle as hunter-gatherers. These changes have had a detrimental effect on Aboriginal health, in part due to immunological modification. This review provides a comparative look at both the traditional Aboriginal/Indigenous diet and modern Western diets, examines some common allergies increasingly reported in contemporary Indigenous populations, and reviews concepts such the effect of vitamin deficiencies and changes in gut microbiota on immune function.

The effectiveness of psychosocial interventions designed to improve health-related quality of life (HRQOL) amongst asthmatic children and their families: a systematic review

PURPOSE

Asthmatic children are at risk of compromised health-related quality of life (HRQOL) compared with their healthy peers. This systematic review reports the range and effectiveness of psychosocial interventions designed to improve HRQOL amongst asthmatic children, adolescents, and their families.

METHOD

Data sources included The Cochrane Airways Group Trials Register of trials, PubMed database, and reference lists from review articles.

RESULTS

Eighteen studies of psychosocial interventions were identified. Interventions were designed to improve HRQOL amongst a range of psychosocial, health care, school-related and clinical outcomes, and were delivered in numerous settings and formats. Four studies reported that interventions were effective for significant improvements in child overall HRQOL scores. These include asthma education (n = 2), asthma education plus problem solving (n = 1), and art therapy (n = 1).

CONCLUSIONS

Most interventions focussed on the delivery of asthma education to children, with the purpose of improving knowledge about asthma and disease management. There is limited evidence to suggest that interventions currently available are effective for significantly improving HRQOL amongst asthmatic children, adolescents, and their families. Most interventions lacked a theoretical basis and did not focus on family functioning variables. Multi-component interventions that incorporate asthma education along with strategies to assist families with implementing behaviour change towards improved asthma management are required. Future interventions should also attempt to address the wider context of family functioning likely to contribute to the family's ability to engage in successful asthma management in order to improve HRQOL.