It is postulated that children with asthma who receive an interactive, comprehensive education program would improve their quality of life, asthma management and asthma control compared with children receiving usual care.
To assess the feasibility and impact of ‘Roaring Adventures of Puff’ (RAP), a six-week childhood asthma education program administered by health professionals in schools.
Thirty-four schools from three health regions in Alberta were randomly assigned to receive either the RAP asthma program (intervention group) or usual care (control group). Baseline measurements from parent and child were taken before the intervention, and at six and 12 months.
The intervention group had more smoke exposure at baseline. Participants lost to follow-up had more asthma symptoms. Improvements were significantly greater in the RAP intervention group from baseline to six months than in the control group in terms of parent’s perceived understanding and ability to cope with and control asthma, and overall quality of life (P<0.05). On follow-up, doctor visits were reduced in the control group.
A multilevel, comprehensive, school-based asthma program is feasible, and modestly improved asthma management and quality of life outcomes. An interactive group education program offered to children with asthma at their school has merit as a practical, cost-effective, peer-supportive approach to improve health outcomes.
Asthma education; Childhood asthma; Program evaluation; Quality of life; School-based program
The escalating competition between online pornography - seeking and disseminating
behaviors and technologies that attempt to reduce them creates
technical, semantic and legal barriers to the legitimate discussion
of and education about sensitive health issues involving sexuality, anatomy
and pathology, especially when image-based knowledge is used. The
effects of this competition on the use and management of an online
dermatology atlas are described with a discussion on the importance of
anticipating, addressing and controlling this problem while developing
and maintaining image-based digital libraries and other e-Health applications.
The concept of asthma self-management began in asthma camps in the 1970s. Today all asthma camps are required to provide an educational asthma self-management program. The interaction between children and educators is brief, and if the children do not continue in an associated program after camp, the benefits may be lost. Open Airways, the first program developed specifically for minority children, has been the prototype for community asthma self-management. School-based intervention programs have incorporated asthma education into the health curriculum. Some asthma education programs include an emphasis on the environment. Another approach is to develop intervention projects with parents, as in the Head Start program. This program has been very effective in increasing early recognition of asthma and decreasing recidivism in a high-risk population. Another type of project addressed the reading ability and reading comprehension of asthmatic children. Improvement in reading skills resulted in a 47% decrease in asthma recidivism. After 18 months, there were only two hospitalizations among the enrolled participants. Asthma self-management programs that are most effective for inner-city children provide an interactive, culturally relevant form of asthma education and address issues such as literacy and continuity.
This article describes the evaluation of a comprehensive school-based asthma management program in an inner-city, largely African-American school system. All 54 elementary schools (combined enrollment 13,247 students) from a single urban school system participated in this study. Schools were randomly divided between immediate and delayed intervention programs. The intervention consisted of 3 separate educational programs (for school faculty/staff, students with asthma, and peers without asthma) and medical management for the children with asthma (including an Individual Asthma Action Plan, medications, and peakflow meters). Children with asthma were identified using a case detection program and 736 were enrolled into the intervention study. No significant differences were observed in school absences, grade point average, emergency room visits, or hospitalizations between the immediate and delayed intervention groups. Significant increases in knowledge were observed in the immediate intervention group. This study of a school-based asthma management education and medical intervention program did not show any differences between the intervention and control groups on morbidity outcomes. Our experience leads us to believe that such measures are difficult to impact and are not always reliable. Future researchers should be aware of the problems associated with using such measures. In addition, connecting children with a regular source of health care in this population was difficult. More intensive methods of medical management, such as school-based health centers or supervised asthma therapy, might prove more effective in inner-city schools.
Among rural children with asthma and their parents, this study examined the relationship between parental and child reports of quality of life and described the relationship of several factors such as asthma severity, missed days of work and asthma education on their quality of life.
Two hundred and one rural families with asthma were enrolled in a school-based educational program. Intervention parents and children received interactive asthma workshop(s), asthma devices and literature. Parent and child quality of life measurements were obtained pre and post intervention using Juniper's Paediatric Caregivers Quality of Life and Juniper's Paediatric Quality of Life Questionnaires. Asthma severity was measured using criteria from the National Asthma Education and Prevention Program (NAEPP) guidelines.
There was no association between parent and child total quality of life scores, and mean parental total quality of life scores were higher at baseline and follow-up than those of the children. All the parents' quality of life scores were correlated with parental reports of missed days of work. For all children, emotional quality of life (EQOL) was significantly associated with parental reports of school days missed (p= .03) and marginally associated with parental reports of hospitalizations due to asthma (p=.0.08). Parent's emotional quality of life (EQOL) and activity quality of life (AQOL) were significantly associated with children's asthma severity (EQOL, p=.009, AQOL, p=0.03), but not the asthma educational intervention. None of the child quality of life measurements were associated with asthma severity.
Asthma interventions for rural families should help families focus on gaining and maintaining low asthma severity levels in order for families to enjoy an optimal quality of life. Health care providers should try to assess the child's quality of life at each asthma care visit independently of the parents.
Asthma self-management education is critical for high-quality asthma care for children. A number of studies have assessed the effectiveness of providing asthma education in schools to augment education provided by primary care providers.
To conduct a systematic review of the literature on school-based asthma education programs.
As our data sources, we used 3 databases that index peer-reviewed literature: MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. Inclusion criteria included publication in English and enrollment of children aged 4 to 17 years with a clinical diagnosis of asthma or symptoms consistent with asthma.
Twenty-five articles met the inclusion criteria. Synthesizing findings across studies was difficult because the characteristics of interventions and target populations varied widely, as did the outcomes assessed. In addition, some studies had major methodologic weaknesses. Most studies that compared asthma education to usual care found that school-based asthma education improved knowledge of asthma (7 of 10 studies), self-efficacy (6 of 8 studies), and self-management behaviors (7 of 8 studies). Fewer studies reported favorable effects on quality of life (4 of 8 studies), days of symptoms (5 of 11 studies), nights with symptoms (2 of 4 studies), and school absences (5 of 17 studies).
Although findings regarding effects of school-based asthma education programs on quality of life, school absences, and days and nights with symptoms were not consistent, our analyses suggest that school-based asthma education improves knowledge of asthma, self-efficacy, and self-management behaviors.
asthma; children; schools; patient education; systematic review
Objective: To evaluate Watch, Discover, Think and Act (WDTA), a theory-based application of CD-ROM educational technology for pediatric asthma self-management education.
Design: A prospective pretest posttest randomized intervention trial was used to assess the motivational appeal of the computer-assisted instructional program and evaluate the impact of the program in eliciting change in knowledge, self-efficacy, and attributions of children with asthma. Subjects were recruited from large urban asthma clinics, community clinics, and schools. Seventy-six children 9 to 13 years old were recruited for the evaluation.
Results: Repeated-measures analysis of covariance showed that knowledge scores increased significantly for both groups, but no between-group differences were found (P = 0.55); children using the program scored significantly higher (P < 0.01) on questions about steps of self-regulation, prevention strategies, and treatment strategies. These children also demonstrated greater selfefficacy (P < 0.05) and more efficacy building attribution classification of asthma self-management behaviors (P < 0.05) than those children who did not use the program.
Conclusion: The WDTA is an intrinsically motivating educational program that has the ability to effect determinants of asthma self-management behavior in 9- to 13-year-old children with asthma. This, coupled with its reported effectiveness in enhancing patient outcomes in clinical settings, indicates that this program has application in pediatric asthma education.
To evaluate the efficacy of behavioral weight control intervention combined with a peer-enhanced activity intervention versus structured aerobic exercise in decreasing BMI and z-BMI in overweight adolescents.
Participants were randomized to one of two group-based treatment conditions: 1) cognitive behavioral treatment combined with peer enhanced adventure therapy (CBT+PEAT) or 2) cognitive behavioral weight control treatment combined with supervised aerobic exercise (CBT+EXER). Participants included 118 overweight adolescents, ages 13 – 16 years, and a primary caregiver. Changes in body mass index (BMI), standardized BMI, percent over BMI, and waist circumference were examined.
Analysis of variance based on intent to treat (ITT) indicated significant decreases in all weight change outcomes at end of treatment, with significant decreases maintained at 12-month follow-up. No differences between treatment conditions were observed. Secondary analyses indicated that adherence with attendance and completion of weekly diet records contributed significantly to reductions in BMI.
A cognitive behavioral weight control intervention combined with supervised aerobic exercise or peer-enhanced adventure therapy is equally effective in short-term reduction of BMI and z-BMI among overweight adolescents. Adherence, as measured by session attendance and self-monitoring, is a key dimension of weight change.
To describe and discuss the health care needs within the sport of adventure racing, specifically relating to the parameters for sports chiropractors serving at such events, and to help further develop these in a scholarly format to assist in overcoming the paucity of such information.
A review of the diminutive literature base available pertaining to adventure racing was used in conjunction with a retrospective analysis of injury statistics from a multi-day adventure race.
Adventure racing is an ultra-endurance, multi-discipline, team sport. Races typically cover great distances, often under brutal conditions and circumstances. Training for and competing in such events frequently causes deleterious health consequences and sports chiropractors are uniquely qualified to provide treatment for most of these problems. Specific preparatory and participatory parameters are discussed to assist the sports chiropractor in his or her health care service role within the sport of adventure racing.
Adventure racing is a new and expanding sport, and so is chiropractic's role of involvement. Few published papers exist in peer-reviewed journals relative to what health care providers can expect at adventure races, and how they can most effectively participate. This paper adds published material to the scientific literature regarding the health care needs and the treatment parameters within the sport of adventure racing.
Athletic Injuries; Chiropractic; Physical Endurance; Sleep Deprivation; Survival; Adventure Racing
Although pharmaceutical management is an integral part of asthma control, few community-based analyses have focused on this aspect of disease management. The primary goal of this analysis was to assess whether participation in the school-based Kickin’ Asthma program improved appropriate asthma medication use among middle school students. A secondary goal was to determine whether improvements in medication use were associated with subsequent improvements in asthma-related symptoms among participating students. Students completed an in-class case-identification questionnaire to determine asthma status. Eligible students were invited to enroll in a school-based asthma curriculum delivered over four sessions by an asthma health educator. Students completed a pre-survey and a 3-month follow-up post-survey that compared symptom frequency and medication use. From 2004 to 2007, 579 participating students completed pre- and post-surveys. Program participation resulted in improvements in appropriate use across all three medication use categories: 20.0% of students initiated appropriate reliever use when “feeling symptoms” (p < 0.001), 41.6% of students reporting inappropriate medication use “before exercise” initiated reliever use (p < 0.001), and 26.5% of students reporting inappropriate medication use when “feeling fine” initiated controller use (p < 0.02). More than half (61.6%) of participants reported fewer symptoms at post-survey. Symptom reduction was not positively associated with improvements in medication use in unadjusted and adjusted analysis, controlling for sex, asthma symptom classification, class attendance, season, and length of follow-up. Participation in a school-based asthma education program significantly improved reliever medication use for symptom relief and prior-to-exercise and controller medication use for maintenance. However, given that symptom reduction was not positively associated with improvement in medication use, pharmaceutical education must be just one part of a comprehensive asthma management agenda that addresses the multifactorial nature of asthma-related morbidity.
Child and adolescent health; Chronic disease; Evaluation; Asthma; Medication use; Reliever; Controller; Exercise-induced
This article reports on the development of a personalized, Web-based asthma-education program for parents whose 4- to 12-year-old children have moderate to severe asthma. Personalization includes computer-based tailored messages and a human coach to build asthma self-management skills. Computerized features include the Asthma Manager, My Calendar/Reminder, My Goals, and a tailored home page. These are integrated with monthly asthma-education phone calls from an asthmanurse case manager. The authors discuss the development process and issues and describe the current randomized evaluation study to test whether the yearlong integrated intervention can improve adherence to a daily asthma controller medication, asthma control, and parent quality of life to reduce asthma-related healthcare utilization. Implications for health education for chronic disease management are raised.
asthma case management; medication adherence-pediatric asthma; pediatric asthma; program development-pediatric asthma; nurse case management; chronic disease selfmanagement; eHealth; interactive health communication
The high prevalence of asthma among children continues to be a major public health issue. In particular, low-income African-American and Hispanic children often receive asthma care in the emergency department and lack access to continuity of care.
The aim of the current study was to test the feasibility of implementing a computerized program for empowering low-income children with asthma to manage their own disease. This pilot program consisted of a guided, personalized, Web-based computer program as the main component of a school-based asthma intervention.
The Automated Live E-Health Response Tracking System (ALERTS), a computer-assisted, Web-based tracking program, was tested for implementation in a school in East Harlem, New York. The program required children with asthma, assisted by trained researchers, to routinely measure their peak flow meter readings and answer a symptom questionnaire. The program provided individualized feedback on their disease status based on peak flow meter input. The computer program sent reports to the child’s physician and the nurse practitioner at the on-site school health center. The children were also encouraged to bring the reports home to their parents. A pre/post study design was employed such that each participant acted as his/her own control. Comparisons of preintervention and postintervention outcomes were calculated using the paired t-test and the McNemar test for dichotomous data.
Twenty-four children (6 to 12 years) participated in the program over 2 to 15 months. Improvements in health outcomes showed the greatest significance among the group of participants who were enrolled for 8 months or longer. Statistically significant improvements were seen in the average physical health score of the children (from 65.64 preintervention to 76.28 postintervention, P = .045). There was a significant decrease in the number of participants experiencing wheezing episodes (n = 9 to n = 2, P = .03), and in the average number of wheezing episodes per child (1.86 to 0.43, P = .02). Although not statistically significant, decreases were also seen in the number of children experiencing an asthma attack and in the average number of asthma attacks among participants. There was also a significant decrease in the average number of visits to doctors’ offices or clinics (1.23 to 0.38, P = .04). There were no overnight hospitalizations in the two-week period following the end of the pilot program, a nonsignificant reduction from an average of 0.21 per child.
This individualized, computer-assisted intervention resulted in improvements in some health outcomes among low-income children in an urban, public school-based setting. Consistent peak flow meter self-measurements, management of medication usage, and a computerized approach to symptom tracking resulted in fewer asthma exacerbations and improved overall physical health among this pediatric population with asthma.
Asthma; disease management; Internet; child; underserved; Asthma Action Plan; outcomes; urban; low-income
Schools are effective venues for providing pediatric asthma education programs. Resources are limited, however, so ideally, these programs should be provided to schools with the highest prevalence. National and state asthma surveillance data cannot be extrapolated to local geographic areas. The objective of this study was to survey local schools on Long Island to obtain this information. Survey forms were mailed to the school nurses at every school in Nassau and Suffolk Counties, New York, in 2004, 2006, 2008, and 2010 asking for the number of children with asthma and the number who had permission to access rescue medication in the school. School nurses completed and returned the forms. We analyzed data from elementary and high schools separately, as high-school students often carry their medications with them without obtaining permission. Of the 3,327 surveys sent, 2,060 (61.9%) were returned and 1,807 (54.3%) could be included in the analyses. Overall, asthma prevalence increased from 7.6% in 2004 to 8.7% in 2010. This mirrored the New York State and national trends, although the rates we found were generally lower. The rate of asthmatic children with permission to access rescue medication in school was about the same throughout the study period (39.7% in 2004 and only 42.3% in 2010). Both rates were lower in elementary schools in low socioeconomic areas. These methods allowed us to compare the burden of childhood asthma in individual responder schools in a relatively large geographic area.
We previously conducted the School Based Asthma Therapy trial to improve adherence to national asthma guidelines for urban children through directly observed administration of preventive asthma medications in school. The trial successfully improved outcomes among these children; however several factors limit its potential for dissemination. To enhance sustainability, we subsequently developed a new model of care using web-based guides for efficient communications and integration within school and community systems. This paper describes the development of the School-Based Preventive Asthma Care Technology (SB-PACT) trial.
We developed the SB-PACT web-based system based on stakeholder feedback, and conducted a pilot randomized trial with 100 children to establish its feasibility in facilitating preventive asthma care for high-risk children. The SB-PACT system represents a new model of care using web-based guides for asthma symptom screening, follow-up control assessments, and electronic communications with providers.
We enrolled and successfully screened all children using the web-based system. Most providers used the electronic communication system without difficulty, and the majority of children in the intervention group received preventive medications through school as planned and dose adjustments as needed. Several challenges to implementation also were encountered.
This program is designed to promote sustainability of school-based asthma care, reduce program costs, and to ultimately succeed in a real-world setting. With further refinements, it has the potential to be implemented nationally in schools.
asthma; school-based; technology; sustainability; preventive care
The School Based Asthma Therapy (SBAT) trial builds on a pilot study in which we found that school-based administration of preventive asthma medications for inner-city children reduced asthma symptoms. However, the beneficial effects of this program were seen only among children not exposed to environmental tobacco smoke (ETS). The current study is designed to establish whether this intervention can be enhanced by more stringent adherence to asthma guidelines through the addition of symptom-based medication dose adjustments, and whether smoke-exposed children benefit from the intervention when it is combined with an ETS reduction program. The intervention consists of both administration of preventive asthma medications in school (with dose adjustments according to NHLBI guidelines) and a home-based ETS reduction program utilizing motivational interviewing principles. This paper describes the methodology, conceptual framework, and lessons learned from the SBAT trial. Results of this study will help to determine whether this type of comprehensive school-based program can serve as a model to improve care for urban children and reduce disparities.
asthma; children; preventive care; schools; environmental tobacco smoke; adherence
To evaluate the impact of the School-Based Asthma Therapy trial on asthma symptoms among urban children with persistent asthma.
Randomized trial, with children stratified by smoke exposure in the home and randomized to a school-based care group or a usual care control group.
Rochester, New York.
Children aged 3 to 10 years with persistent asthma.
Directly observed administration of daily preventive asthma medications by school nurses (with dose adjustments according to National Heart, Lung, and Blood Institute Expert Panel guidelines) and a home-based environmental tobacco smoke reduction program for smoke-exposed children, using motivational interviewing.
Main Outcome Measure
Mean number of symptom-free days per 2 weeks during the peak winter season (November-February), assessed by blinded interviews.
We enrolled 530 children (74% participation rate). During the peak winter season, children receiving preventive medications through school had significantly more symptom-free days compared with children in the control group (adjusted difference=0.92 days per 2 weeks; 95% confidence interval, 0.50-1.33) and also had fewer nighttime symptoms, less rescue medication use, and fewer days with limited activity (allP<.01). Children in the treatment group also were less likely than those in the control group to have an exacerbation requiring treatment with prednisone (12% vs 18%, respectively; relative risk=0.64; 95% confidence interval, 0.41-1.00). Stratified analyses showed positive intervention effects even for children with smoke exposure (n=285; mean symptom-free days per 2 weeks: 11.6 for children in the treatment group vs 10.9 for those in the control group; difference=0.96 days per 2 weeks; 95% confidence interval, 0.39-1.52).
The School-Based Asthma Therapy intervention significantly improved symptoms among urban children with persistent asthma. This program could serve as a model for improved asthma care in urban communities.
OBJECTIVE--To determine whether an intervention programme based on existing school and community resources can reduce school absence and improve participation in games lessons and sport in children with unrecognised or undertreated asthma. DESIGN--Parallel group controlled intervention study. SETTING--102 primary schools in Nottingham: 49 were randomised to receive the intervention and 53 to be control schools. SUBJECTS--All children aged 5 to 10 years with parent reported absence from school because of wheezing in the previous year and taking no treatment or beta agonists only. INTERVENTIONS--Children with asthma were referred to their general practitioner for assessment of symptoms and treatment. Teachers were given education on asthma by the school nurse in 44 of the 49 intervention schools. MAIN OUTCOME MEASURES--Changes in school absence and missed games and swimming lessons because of wheezing, and schools' policy towards management of asthma in school. RESULTS--Of 17,432 children screened, 451 met the entry criteria--228 in intervention schools and 223 in control schools. 152 (67%) children in intervention schools visited their general practitioner, of whom 39 (26%) were given a new diagnosis of asthma and 58 (38%) had treatment for asthma increased or changed. Over the next academic year mean (SE) parent reported school absence due to wheezing fell significantly, but to a similar extent, in both intervention and control schools (0.82 (0.11) and 1.09 (0.21) weeks respectively). There was little change in school recorded absence or participation in games lessons and swimming lessons in either group. At the end of the study intervention schools were more likely to have improved aspects of management of asthma in school. CONCLUSION--The intervention resulted in a majority of children being assessed by their general practitioner and improved teachers' understanding and management of asthma, but it did not result in any appreciable reduction in morbidity.
Self-monitoring of symptoms or peak flow monitoring (PFM) is recommended for all asthma patients and is commonly included in asthma management plans. Limited data are available documenting PFM outcomes in school settings.
Three hundred twenty-three urban children with persistent asthma were enrolled in a school-based study that implemented an internet-based asthma monitoring and data collection system. The mean age of the children was 10.0 (SD 2.1) years; 57% were male and 91% were African American. Children logged in daily to an internet-based program to record their asthma symptoms and PFM reading. Teachers logged in daily to confirm the PFM readings. School staff responsible for student health reported actions taken for low PFM readings.
A total of 12,245 child reports were completed; 98% (n=11,974) had corresponding teacher reports, confirming the peak flow meter readings reported by the children. The prevalence of reported asthma symptoms varied across PFM readings; the highest prevalence occurred in the setting of red zone readings, with intermediate prevalence in the setting of yellow zone readings, and lowest prevalence in the setting of green zone readings. The actions reported in response to children’s symptoms and peak flow results similarly varied; however, instances of no action were reported in the setting of yellow and red zone readings. When comparing the “worst days” of children who had ever had a red or yellow PFM reading with those of children who only had exhibited green, there was a nonsignificant trend toward fewer symptoms in the green-only group. Additionally, there was a nonsignificant trend toward a greater likelihood of being sent to the office or school nurse with greater symptoms in the setting of a yellow or red zone reading.
On the whole, peak flow readings tended to correspond to asthma disease activity. However, the data indicate that school staff may be more inclined to take action based on their own perceptions of a child’s asthma or respond to children’s subjective reports of asthma symptoms rather than using a more objective measure of disease activity provided by a peak flow meter.
asthma; peak flow; school; children; wheeze
The Controlling Asthma in American Cities Project (CAACP) was designed to improve the control of asthma in inner-city populations of children with a disparate burden of symptoms and adverse outcomes. As with many chronic diseases, asthma is the manifestation of multiple biologic, environmental, and social determinants. In addition to appropriate medical management, individuals with asthma must have logistical, financial, and cultural access to environments that allow avoidance of asthma triggers and encourage good asthma management practices. In recognition of this complexity, the CAACP required the seven project sites to coordinate and synchronize multiple interventions (education, healthcare access, medical management, trigger reduction) at multiple levels (individual, home, school, community, and policy) through the collaboration of relevant groups, institutions, and individuals. This paper describes the “program theory” of the CAACP project—the assumptions about how the project worked, how the components were linked, and what outcomes were anticipated. It relates the subsequent papers in the supplement to the program theory and describes how the papers can inform and guide other community-based interventions, and advance the translation of scientific knowledge to effective interventions in communities of need.
Community health partnerships; Coalitions; Asthma; Inner-city; Program theory; Ecological model of behavior change
Rationale: Urban African-American youth, aged 15–19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing.
Objectives: Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses “tailoring,” in conjunction with theory-based models, to alter behavior through individualized health messages based on the user's beliefs, attitudes, and personal barriers to change.
Methods: High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers.
Measurements and Main Results: Functional status and medical care use were measured at study initiation and 12 months postbaseline, as were selected management behaviors. The intervention period was 180 days (calculated from baseline). A total of 314 students were randomized (98% African American, 49% Medicaid enrollees; mean age, 15.2 yr). At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students; adjusted relative risk and 95% confidence intervals were as follows: 0.5 (0.4–0.8), p = 0.003; 0.4 (0.2–0.8), p = 0.009; 0.3 (0.1–0.7), p = 0.006; 0.5 (0.3–0.8), p = 0.02; and 0.2 (0.2–0.9), p = 0.01, respectively. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per participating treatment group student.
Conclusions: A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population.
asthma; urban; adolescents; school-based; web-based
Urban African-American youth, aged 15–19 years, have asthma fatality rates that are higher than in whites and younger children, yet few programs target this population. Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing.
Develop and evaluate a multimedia, web-based asthma management program to specifically target urban high school students. The program uses “tailoring,” in conjunction with theory-based models, to alter behavior through individualized health messages based on the user’s beliefs, attitudes, and personal barriers to change.
High school students reporting asthma symptoms were randomized to receive the tailored program (treatment) or to access generic asthma websites (control). The program was made available on school computers.
Measurements and Main Results
Functional status and medical care use were measured at study initiation and 12 months postbaseline, as were selected management behaviors. The intervention period was 180 days (calculated from baseline). A total of 314 students were randomized (98% African American, 49% Medicaid enrollees; mean age, 15.2 yr). At 12 months, treatment students reported fewer symptom-days, symptom-nights, school days missed, restricted-activity days, and hospitalizations for asthma when compared with control students; adjusted relative risk and 95% confidence intervals were as follows: 0.5 (0.4–0.8), p = 0.003; 0.4 (0.2–0.8), p = 0.009; 0.3 (0.1–0.7), p = 0.006; 0.5 (0.3–0.8), p = 0.02; and 0.2 (0.2–0.9), p = 0.01, respectively. Positive behaviors were more frequently noted among treatment students compared with control students. Cost estimates for program delivery were $6.66 per participating treatment group student.
A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population.
asthma; urban; adolescents; school-based; web-based
Asthma is a chronic lung disease that affects more than 23 million people in the United States, including 7 million children. Asthma is a difficult to manage chronic condition associated with disparities in health outcomes, poor medical compliance, and high healthcare costs. The research network coordinating this project includes hospitals, urgent care centers, and outpatient clinics within Carolinas Healthcare System that share a common electronic medical record and billing system allowing for rapid collection of clinical and demographic data. This study investigates the impact of three interventions on clinical outcomes for patients with asthma. Interventions are: an integrated approach to care that incorporates asthma management based on the chronic care model; a shared decision making intervention for asthma patients in underserved or disadvantaged populations; and a school based care approach that examines the efficacy of school-based programs to impact asthma outcomes including effectiveness of linkages between schools and the healthcare providers.
This study will include 95 Practices, 171 schools, and over 30,000 asthmatic patients. Five groups (A-E) will be evaluated to determine the effectiveness of three interventions. Group A is the usual care control group without electronic medical record (EMR). Group B practices are a second control group that has an EMR with decision support, asthma action plans, and population reports at baseline. A time delay design during year one converts practices in Group B to group C after receiving the integrated approach to care intervention. Four practices within Group C will receive the shared decision making intervention (and become group D). Group E will receive a school based care intervention through case management within the schools. A centralized database will be created with the goal of facilitating comparative effectiveness research on asthma outcomes specifically for this study. Patient and community level analysis will include results from patient surveys, focus groups, and asthma patient density mapping. Community variables such as income and housing density will be mapped for comparison. Outcomes to be measured are reduced hospitalizations and emergency department visits; improved adherence to medication; improved quality of life; reduced school absenteeism; improved self-efficacy and improved school performance.
Identifying new mechanisms that improve the delivery of asthma care is an important step towards advancing patient outcomes, avoiding preventable Emergency Department visits and hospitalizations, while simultaneously reducing overall healthcare costs.
asthma; comparative effectiveness research; shared decision making; integrated approach to care
Caregivers who smoke and have children with asthma are an important group for intervention. Home-based interventions successfully reduce asthma morbidity, yet are costly. This study evaluated the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program, a combined asthma education and smoking cessation intervention.
Participants included caregivers (n = 224) that smoked, had a child with asthma, and were enrolled in a Medicaid managed care plan. Participants received nurse-delivered asthma education and smoking counseling in three home visits. Program implementation costs were estimated, and health care expenses were obtained from insurance claims data 12 months pre- and 12 months post intervention. ROI was calculated for all participants, children < 6 years, children 6–18 years, and children with moderate/severe persistent asthma.
Total program implementation cost was $34,481. After intervention, there was increased mean annual refills of beta-agonist (0.51 pre, 1.64 post; p<0.001), and controller medications (0.65 pre, 2.44 post; p<0.001). Reductions were found in mean annual emergency department visits (0.33 pre, 0.14 post; p<0.001), hospitalizations (0.23 pre, 0.08 post; p<0.001), and outpatient visits (2.33 pre, 1.45 post, p<0.001). The program had negative ROI (−21.8%) for the entire sample. The ROI was positive (+106.9) for children < six years, negative (−150.3) for children 6–18, and negligible for moderate/severe persistent asthma (+6.9%).
PAQS was associated with increased medication use and decreased health care utilization. While the overall ROI for PAQS was negative, PAQS had a positive ROI for caregivers of young children with asthma.
Asthma; Pediatrics; Smoking Cessation; Education
Many children with asthma live with frequent symptoms and activity limitations, and visits for urgent care are common. Many pediatricians do not regularly meet with families to monitor asthma control, identify concerns or problems with management, or provide self-management education. Effective interventions to improve asthma care such as small group training and care redesign have been difficult to disseminate into office practice.
Methods and design
This paper describes the protocol for a randomized controlled trial (RCT) to evaluate a 12-month telephone-coaching program designed to support primary care management of children with persistent asthma and subsequently to improve asthma control and disease-related quality of life and reduce urgent care events for asthma care. Randomization occurred at the practice level with eligible families within a practice having access to the coaching program or to usual care. The coaching intervention was based on the transtheoretical model of behavior change. Targeted behaviors included 1) effective use of controller medications, 2) effective use of rescue medications and 3) monitoring to ensure optimal control. Trained lay coaches provided parents with education and support for asthma care, tailoring the information provided and frequency of contact to the parent's readiness to change their child's day-to-day asthma management. Coaching calls varied in frequency from weekly to monthly. For each participating family, follow-up measurements were obtained at 12- and 24-months after enrollment in the study during a telephone interview.
The primary outcomes were the mean change in 1) the child's asthma control score, 2) the parent's quality of life score, and 3) the number of urgent care events assessed at 12 and 24 months. Secondary outcomes reflected adherence to guideline recommendations by the primary care pediatricians and included the proportion of children prescribed controller medications, having maintenance care visits at least twice a year, and an asthma action plan. Cost-effectiveness of the intervention was also measured.
Twenty-two practices (66 physicians) were randomized (11 per treatment group), and 950 families with a child 3-12 years old with persistent asthma were enrolled. A description of the coaching intervention is presented.
ClinicalTrials.gov identifier NCT00860834.
Asthma; Behavioral skills training; Lay coaching
Objective This article presents a summary of findings from asthma studies focusing on immigration and acculturation-related factors. A study examining associations between these processes, family cohesion and social support networks, and asthma morbidity in a sample of Dominican and Puerto Rican caregivers residing in the mainland U.S., is also described. Methods Latino children with asthma (n = 232), ages 7–16 (49% female) and their caregivers completed interview-based questionnaires on immigration and acculturation-related processes, family characteristics, and asthma morbidity. Results The frequency of ED use due to asthma may be higher for children of caregivers born in Puerto Rico. Acculturative stress levels were higher for Puerto Rican born caregivers residing in the mainland U.S. Conclusion Asthma-related educational and intervention programs for Latino children and families should be tailored to consider the effects that the immigration and acculturation experience can have on asthma management. Specific family-based supports focused on decreasing stress related to the acculturation process, and increasing social and family support around the asthma treatment process may help to reduce asthma morbidity in Latino children.
acculturation; asthma morbidity; immigration