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1.  Challenges in Providing Preventive Care To Inner-city Children with Asthma 
PMCID: PMC3651828  PMID: 23659811
asthma; inner-city; preventive care
2.  Factors Associated with Completion of a Behavioral Intervention for Caregivers of Urban Children with Asthma 
Rates of preventive follow-up asthma care after an acute emergency department (ED) visit are low among inner-city children. We implemented a novel behavioral asthma intervention, Pediatric Asthma Alert (PAAL) intervention, to improve outpatient follow-up and preventive care for urban children with a recent ED visit for asthma.
The objective of this article is to describe the PAAL intervention and examine factors associated with intervention completers and noncompleters.
Children with persistent asthma and recurrent ED visits (N = 300) were enrolled in a randomized controlled trial of the PAAL intervention that included two home visits and a facilitated follow-up visit with the child’s primary care provider (PCP). Children were categorized as intervention completers, that is, completed home and PCP visits compared with noncompleters, who completed at least one home visit but did not complete the PCP visit. Using chi-square test of independence, analysis of variance, and multiple logistic regression, the intervention completion status was examined by several sociodemographic, health, and caregiver psychological variables.
Children were African-American (95%), Medicaid insured (91%), and young (aged 3–5 years, 56%). Overall, 71% of children randomized to the intervention successfully completed all home and PCP visits (completers). Factors significantly associated with completing the intervention included younger age (age 3–5 years: completers, 65.4%; noncompleters, 34.1%; p < .001) and having an asthma action plan in the home at baseline (completers: 40%; noncompleters: 21%; p = .02). In a logistic regression model, younger child age, having an asthma action plan, and lower caregiver daily asthma stress were significantly associated with successful completion of the intervention.
The majority of caregivers of high-risk children with asthma were successfully engaged in this home and PCP-based intervention. Caregivers of older children with asthma and those with high stress may need additional support for program completion. Further, the lack of an asthma action plan may be a marker of preexisting barriers to preventive care.
PMCID: PMC3773483  PMID: 22991952
asthma; children; controller medications; inner city; preventive care
3.  Factors Associated with Second Hand Smoke Exposure In Young Inner City Children with Asthma 
To examine the association of social and environmental factors with levels of second hand smoke (SHS) exposure, as measured by salivary cotinine, in young inner city children with asthma.
We used data drawn from a home-based behavioral intervention for young high risk children with persistent asthma post emergency department (ED) treatment (N=198). SHS exposure was measured by salivary cotinine and caregiver report. Caregiver demographic and psychological functioning, household smoking behavior and asthma morbidity were compared with child cotinine concentrations. Chi-square and ANOVA tests and multivariate regression models were used to determine the association between cotinine concentrations with household smoking behavior and asthma morbidity.
Over half (53%) of the children had cotinine levels compatible with SHS exposure and mean cotinine concentrations were high at 2.42 ng/ml (SD 3.2). The caregiver was the predominant smoker in the home (57%) and (63%) reported a total home smoking ban. Preschool age children, and those with caregivers reporting depressive symptoms and high stress had higher cotinine concentrations than their counterparts. Among children living in a home with a total home smoking ban, younger children had significantly higher mean cotinine concentration than older children (Cotinine: 3–5 year olds, 2.24 ng/ml (SD 3.5); 6–10 year olds, 0.63 ng/ml (SD 1.0); p <0.05). In multivariate models, the factors most strongly associated with high child cotinine concentrations were increased number of household smokers (β = 0.24) and younger child age (3–5 years) (β = 0.23; P <0.001, R2 = 0.35).
Over half of young inner-city children with asthma were exposed to second hand smoke and caregivers are the predominant household smoker. Younger children and children with depressed and stressed caregivers are at significant risk of smoke exposures, even when a household smoking ban is reported. Further advocacy for these high-risk children is needed to help caregivers quit and to mitigate smoke exposure.
PMCID: PMC3113681  PMID: 21545248
asthma; children; cotinine; second hand smoke
4.  Patterns of Inhaled Antiinflammatory Medication Use in Young Underserved Children With Asthma 
Pediatrics  2006;118(6):2504-2513.
Asthma guidelines advocate inhaled corticosteroids as the cornerstone treatment of persistent asthma, yet several studies report underuse of inhaled corticosteroids in children with persistent asthma. Moreover, few studies use objective pharmacy data as a measure of drug availability of asthma medications. We examined factors associated with the use of inhaled corticosteroids in young underserved children with persistent asthma using pharmacy records as their source of asthma medications.
This was a cross-sectional analysis of questionnaire and pharmacy record data over a 12-month period from participants enrolled in a randomized clinical trial of a nebulizer educational intervention.
Although exposure to ≥1 inhaled corticosteroids refill was high at 72%, 1 of 5 children with persistent asthma had either no medication or only short-acting β agonist fills for 12 months. Only 20% of children obtained ≥6 inhaled corticosteroids fills over 12 months. Obtaining ≥3 inhaled corticosteroids fills over 12 months was significantly associated with an increase in short-acting β agonist fills and receiving specialty care in the regression models while controlling for child age, asthma severity, number of emergency department visits, having an asthma action plan, and seeking preventive care for the child’s asthma.
Overreliance on short-acting β agonist and underuse of inhaled corticosteroid medications was common in this group of young children with persistent asthma. Only one fifth of children obtained sufficient controller medication fills.
PMCID: PMC2290000  PMID: 17142537
asthma; children; preventive care; antiinflammatory
5.  Improving Asthma Communication in High-Risk Children 
Few child asthma studies address the specific content and techniques needed to enhance child communication during asthma preventive care visits. This study examined the content of child and parent communications regarding their asthma management during a medical encounter with their primary care provider (PCP). The majority of parents and children required prompting to communicate symptom information to the PCP during the clinic visit. Some high-risk families may require an asthma advocate to ensure that the clinician receives an accurate report of child’s asthma severity and asthma control to ensure prescribing of optimal asthma therapy.
PMCID: PMC2275667  PMID: 17994404
childhood asthma; communication educational intervention; prompting
6.  Effectiveness of Nebulizer Use–Targeted Asthma Education on Underserved Children With Asthma 
To determine the effectiveness of a home-based asthma education intervention in increasing appropriate nebulizer use and reducing symptom frequency, emergency department (ED) visits, and hospitalizations over 12 months.
A randomized clinical trial.
Pediatric primary care, pulmonary/allergy, and ED practices associated with the University of Maryland Medical System and The Johns Hopkins Hospital, Baltimore.
Children with persistent asthma, aged 2 to 9 years, with regular nebulizer use and an ED visit or hospitalization within the past 12 months. Children were randomized into the intervention (n=110) or control (n=111) group. Follow-up data were available for 95 intervention and 86 control children.
Home-based asthma education, including symptom recognition, home treatment of acute symptoms, appropriate asthma medication, and nebulizer practice.
Main Outcome Measures
Estimates of mean differences in asthma symptom frequency, number of ED visits and hospitalizations and appropriate quick relief, controller medication, and nebulizer practice over 12 months.
Of the 221 children, 181 (81.9%) completed the study. There were no significant differences in home nebulizer practice, asthma morbidity, ED visits, or hospitalizations between groups (P range, .11–.79). Although most children received appropriate nonurgent asthma care (mean, 2 visits per 6 months), more than one third of all children received at least 6 quick-relief medication prescriptions during 12 months, with no difference by group.
A nebulizer education intervention had no effect on asthma severity or health care use. Of concern is the high quick-relief and low controller medication use in young children with asthma seen nearly every 3 months for nonurgent care.
PMCID: PMC2269706  PMID: 16754825
7.  Shared Decision Making In School Age Children with Asthma 
Pediatric nursing  2007;33(2):111-116.
Shared decision making in health care is a mutual partnership between the health care provider and the patient. Traditionally, children have had little involvement during their medical care visits or in decisions regarding their health care. Shared decision making in children with asthma may enhance their self-confidence as well as improve their self-management skills. Allowing the child to participate during the visit requires assessing the child’s competence at different ages and abilities. Specific communication techniques to use with children during medical encounters include visual aids, turn-taking, clarifying communication, and role modeling. Providers additionally can offer strategies to parents on how to provide general information about asthma and treatments based on the child’s questions and interest. The goal for school age children with asthma is to change dyadic interactions between the provider and parent into triadic interactions to improve the child’s asthma management.
PMCID: PMC2269724  PMID: 17542232
8.  Interventions to Modify Health Care Provider Adherence to Asthma Guidelines: A Systematic Review 
Pediatrics  2013;132(3):517-534.
Health care provider adherence to asthma guidelines is poor. The objective of this study was to assess the effect of interventions to improve health care providers’ adherence to asthma guidelines on health care process and clinical outcomes.
Data sources included Medline, Embase, Cochrane CENTRAL Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, and Research and Development Resource Base in Continuing Medical Education up to July 2012. Paired investigators independently assessed study eligibility. Investigators abstracted data sequentially and independently graded the evidence.
Sixty-eight eligible studies were classified by intervention: decision support, organizational change, feedback and audit, clinical pharmacy support, education only, quality improvement/pay-for-performance, multicomponent, and information only. Half were randomized trials (n = 35). There was moderate evidence for increased prescriptions of controller medications for decision support, feedback and audit, and clinical pharmacy support and low-grade evidence for organizational change and multicomponent interventions. Moderate evidence supports the use of decision support and clinical pharmacy interventions to increase provision of patient self-education/asthma action plans. Moderate evidence supports use of decision support tools to reduce emergency department visits, and low-grade evidence suggests there is no benefit for this outcome with organizational change, education only, and quality improvement/pay-for-performance.
Decision support tools, feedback and audit, and clinical pharmacy support were most likely to improve provider adherence to asthma guidelines, as measured through health care process outcomes. There is a need to evaluate health care provider-targeted interventions with standardized outcomes.
PMCID: PMC4079294  PMID: 23979092
asthma; systematic review; guidelines
10.  Stress and Quality of Life in Caregivers of Inner-city Minority Children with Poorly Controlled Asthma 
Caregiver quality of life (QOL) is known to influence asthma management behaviors. Risk factors for low caregiver QOL in families of inner-city children with asthma remain unclear. This study evaluated the interrelationships of asthma control, stress, and caregiver QOL.
Data were analyzed from a home-based behavioral intervention for children with persistent asthma post asthma emergency department treatment. Caregivers reported on baseline demographics, asthma control, asthma management stress, life stress, and QOL. Hierarchical regression analysis examined the contributions of socio-demographic factors, asthma control, asthma management stress, and life stress in explaining caregiver QOL.
Children (N=300) were primarily African-American (96%) and young (Mean age of 5.5 years). Caregivers were predominantly the biological mother (92%), single (70%), and unemployed (54%). Poor QOL was associated with higher caregiver education and number of children in the home, low asthma control, and increased asthma management stress and life stress. The model accounted for 28% of variance in caregiver QOL.
Findings underscore the need for multi-faceted interventions to provide caregivers of children with asthma tools to cope with asthma management demands and contemporary life stressors.
PMCID: PMC3575578  PMID: 23414978
asthma; caregiver; stress; quality of life
11.  Prospective Relationship between Maternal Depressive Symptoms and Asthma Morbidity among Inner-City African American Children 
Journal of Pediatric Psychology  2009;35(7):758-767.
Objective To examine prospective relationships between caregiver's depressive symptoms and child asthma morbidity among inner-city African American families. Methods Phone surveys were conducted 6 months apart with 262 African American mothers of children with asthma. Cross-lagged structural path analysis was used for data analyses. Results Using goodness-of-fit indices, the final model for asthma symptoms had a good fit to the data. Time 1 (T1) maternal depressive symptoms predicted T2 child asthma symptoms (β =.16, p <.01); however, T1 asthma symptoms did not predict T2 maternal depressive symptoms (β =.03, non-significant). In contrast, in the final model for emergency department (ED) visits there was no predictive association between maternal depressive symptoms and ED visits. Conclusion Maternal depressive symptoms may have a detrimental effect on child asthma morbidity among inner-city African American families, rather than vice versa. Ameliorating maternal depressive symptoms may result in better asthma outcomes for inner-city children.
PMCID: PMC2915621  PMID: 19850709
African American; asthma; depressive symptoms; inner-city
12.  Household Smoking Behavior: Effects on Indoor Air Quality and Health of Urban Children with Asthma 
Maternal and child health journal  2011;15(4):460-468.
The goal of the study was to examine the association between biomarkers and environmental measures of second hand smoke (SHS) with caregiver, i.e. parent or legal guardian, report of household smoking behavior and morbidity measures among children with asthma. Baseline data were drawn from a longitudinal intervention for 126 inner city children with asthma, residing with a smoker. Most children met criteria for moderate to severe persistent asthma (63%) versus mild intermittent (20%) or mild persistent (17%). Household smoking behavior and asthma morbidity were compared with child urine cotinine and indoor measures of air quality including fine particulate matter (PM2.5) and air nicotine (AN). Kruskal–Wallis, Wilcoxon rank-sum and Spearman rho correlation tests were used to determine the level of association between biomarkers of SHS exposure and household smoking behavior and asthma morbidity. Most children had uncontrolled asthma (62%). The primary household smoker was the child's caregiver (86/126, 68%) of which 66 (77%) were the child's mother. Significantly higher mean PM2.5, AN and cotinine concentrations were detected in households where the caregiver was the smoker (caregiver smoker: PM2.5 μg/m3: 44.16, AN: 1.79 μg/m3, cotinine: 27.39 ng/ml; caregiver non-smoker: PM2.5: 28.88 μg/m3, AN: 0.71 μg/m3, cotinine:10.78 ng/ml, all P ≤ 0.01). Urine cotinine concentrations trended higher in children who reported 5 or more symptom days within the past 2 weeks (>5 days/past 2 weeks, cotinine: 28.1 ng/ml vs. <5 days/past 2 weeks, cotinine: 16.2 ng/ml; P = 0.08). However, environmental measures of SHS exposures were not associated with asthma symptoms. Urban children with persistent asthma, residing with a smoker are exposed to high levels of SHS predominantly from their primary caregiver. Because cotinine was more strongly associated with asthma symptoms than environmental measures of SHS exposure and is independent of the site of exposure, it remains the gold standard for SHS exposure assessment in children with asthma.
PMCID: PMC3113654  PMID: 20401688
Asthma; Children; Cotinine; Particulate matter; Air Nicotine
13.  Indoor Air Pollution and Asthma in Children 
The purpose of this article is to review indoor air pollution factors that can modify asthma severity, particularly in inner-city environments. While there is a large literature linking ambient air pollution and asthma morbidity, less is known about the impact of indoor air pollution on asthma. Concentrating on the indoor environments is particularly important for children, since they can spend as much as 90% of their time indoors. This review focuses on studies conducted by the Johns Hopkins Center for Childhood Asthma in the Urban Environment as well as other relevant epidemiologic studies. Analysis of exposure outcome relationships in the published literature demonstrates the importance of evaluating indoor home environmental air pollution sources as risk factors for asthma morbidity. Important indoor air pollution determinants of asthma morbidity in urban environments include particulate matter (particularly the coarse fraction), nitrogen dioxide, and airborne mouse allergen exposure. Avoidance of harmful environmental exposures is a key component of national and international guideline recommendations for management of asthma. This literature suggests that modifying the indoor environment to reduce particulate matter, NO2, and mouse allergen may be an important asthma management strategy. More research documenting effectiveness of interventions to reduce those exposures and improve asthma outcomes is needed.
PMCID: PMC3266016  PMID: 20427579
particulate matter; air pollution; pediatric; urban; bronchial hyperreactivity
14.  Prenatal Drug Exposure: Effects on Cognitive Functioning at 5 Years of Age 
Clinical pediatrics  2007;47(1):58-65.
The goal of this cross-sectional study was to compare cognitive functioning at age 5 years in prenatal drug-exposed children with nondrug-exposed children from a comparable inner-city environment. Children with prenatal drug exposure scored significantly lower on measures of language, school readiness skills, impulse control, and visual attention span/sequencing than controls matched for age and socioeconomic status. Intelligence, visual-motor, manual dexterity, and sustained attention scores were not significantly different between groups. The total sample scored significantly below the normative mean on standardized measures of intelligence, language, school readiness, visual-motor skills, impulse control, and sustained attention, with 40% scoring at least 1 standard deviation below the mean (IQ <85) on a measure of intelligence. Findings suggest that children with prenatal drug exposure are at increased risk for learning and attention problems and are in need of close developmental surveillance and possible intervention to support school success and improve behavioral outcome.
PMCID: PMC2269702  PMID: 17766581
prenatal drug exposure; intelligence; impulsivity; attention

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