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1.  The Impact of Parents’ Medication Beliefs on Asthma Management 
Pediatrics  2007;120(3):e521-e526.
Previous studies suggest a relationship between parental beliefs about asthma medications and medication adherence. It is not clear how parents’ positive and negative feelings about medications interact to influence medication adherence.
The objectives of this study were to describe parents’ perceived need for and concerns about their child’s asthma medications and to assess the weighted impact of these positive and negative beliefs on parent-reported adherence.
We conducted a cross-sectional survey of parents of children with asthma in southeast Michigan; response rate was 71%. Children with reported use of a preventive asthma medication were included (n = 622). We used a validated Beliefs About Medications Questionnaire (2 subscales: necessity and concern) to assess parents’ positive and negative attitudes about their child’s medications. To measure how parents weigh these beliefs, we also calculated a necessity-concern differential score (difference between necessity and concern subscales). We used a 4-item parent-report scale to measure medication adherence.
The majority of children were nonminority. Overall, 72% of parents felt that their child’s asthma medications were necessary, and 30% had strong concerns about the medications. For 77% of parents, necessity scores were higher than concern scores, and for 17%, concern exceeded necessity. Nonminority parents were more likely to have necessity scores exceed concern scores compared with minority parents (79% vs 68%). Mean adherence scores increased as the necessity-concern differential increased. In a multivariate mixed-model regression, a greater necessity-concern differential score and being nonminority predicted better adherence.
These findings confirm a relationship between medication beliefs and adherence among parents of children with asthma. A better understanding of parents’ medication beliefs and their impact on adherence may help clinicians counsel effectively to promote adherence.
PMCID: PMC4335716  PMID: 17766496
beliefs about medications; asthma; minority parents; adherence
2.  Asthma Outcomes: Quality of Life 
“Asthma-related quality of life” refers to the perceived impact that asthma has on the patient’s quality of life.
National Institutes of Health (NIH) institutes and other federal agencies convened an expert group to recommend standardized measures of the impact of asthma on quality of life for use in future asthma clinical research.
We reviewed published documentation regarding the development and psychometric evaluation; clinical research use since 2000; and extent to which the content of each existing quality of life instrument provides a unique, reliable, and valid assessment of the intended construct. We classified instruments as core (required in future studies), supplemental (used according to the study’s aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an NIH-organized workshop convened in March 2010 and finalized in September 2011.
Eleven instruments for adults and 6 for children were identified for review. None qualified as core instruments because they predominantly measured indicators of asthma control (symptoms and/or functional status); failed to provide a distinct, reliable score measuring all key dimensions of the intended construct; and/or lacked adequate psychometric data.
In the absence of existing instruments that meet the stated criteria, currently available instruments are classified as either supplemental or emerging. Research is strongly recommended to develop and evaluate instruments that provide a distinct, reliable measure of the patient’s perception of the impact of asthma on all of the key dimensions of quality of life, an important outcome that is not captured in other outcome measures.
PMCID: PMC4269375  PMID: 22386511
Asthma burden; asthma-related well-being; health perceptions; health status; patient-reported outcomes
3.  Mediators of Asthma Outcomes 
Patient adherence, the level of asthma self-management skills, exposure to stress, and depression can have considerable influence on a wide range of asthma outcomes, and thus are considered asthma outcome mediators.
National Institutes of Health (NIH) institutes and other federal agencies convened an expert group to recommend standardized measures for 7 domains of asthma clinical research outcomes measures. Although the review of mediators of these outcomes was not within the scope of any specific outcome topic, a brief summary is presented so that researchers might consider potential mediators.
We prepared a summary of key mediators of asthma outcomes, based on expertise and knowledge of the literature.
The rationale for including measures of adherence, self-management skills, and exposures to stress in asthma clinical research is presented, along with a brief review of instruments for collecting this information from clinical research participants.
Appropriate measurement of adherence, self-management skills, and exposures to stress will enhance characterization of study participants and provide information about the potential impact these factors can have on mediating the effects of treatment interventions.
PMCID: PMC4261222  PMID: 22386506
Adherence; self-management skills; asthma patient education; stress
4.  The Impact of Neighborhood Socioeconomic Status and Race on the Prescribing of Opioids in Emergency Departments Throughout the United States 
Journal of General Internal Medicine  2013;28(12):1604-1610.
Racial and ethnic disparities in opioid prescribing in the emergency department (ED) are well described, yet the influence of socioeconomic status (SES) remains unclear.
(1) To examine the effect of neighborhood SES on the prescribing of opioids for moderate to severe pain; and (2) to determine if racial disparities in opioid prescribing persist after accounting for SES.
We used cross-sectional data from the National Hospital Ambulatory Medical Care Survey between 2006 and 2009 to examine the prescribing of opioids to patients presenting with moderate to severe pain (184 million visits). We used logistic regression to examine the association between the prescribing of opioids, SES, and race. Models were adjusted for age, sex, pain-level, injury-status, frequency of emergency visits, hospital type, and region.
Our primary outcome measure was whether an opioid was prescribed during a visit for moderate to severe pain. SES was determined based on income, percent poverty, and educational level within a patient’s zip code.
Opioids were prescribed more frequently at visits from patients of the highest SES quartile compared to patients in the lowest quartile, including percent poverty (49.0 % vs. 39.4 %, P < 0.001), household income (47.3 % vs. 40.7 %, P < 0.001), and educational level (46.3 % vs. 42.5 %, P = 0.01). Black patients were prescribed opioids less frequently than white patients across all measures of SES. In adjusted models, black patients (AOR 0.73; 95 % CI 0.66–0.81) and patients from poorer areas (AOR 0.76; 95 % CI 0.68–0.86) were less likely to receive opioids after accounting for pain-level, age, injury-status, and other covariates.
Patients presenting to emergency departments from lower SES regions were less likely to receive opioids for equivalent levels of pain than those from more affluent areas. Black and Hispanic patients were also less likely to receive opioids for equivalent levels of pain than whites, independent of SES.
PMCID: PMC3832731  PMID: 23797920
disparities; pain control; controlled medication; opioid
5.  The Development of an Automated Device for Asthma Monitoring for Adolescents: Methodologic Approach and User Acceptability 
JMIR mHealth and uHealth  2014;2(2):e27.
Many adolescents suffer serious asthma related morbidity that can be prevented by adequate self-management of the disease. The accurate symptom monitoring by patients is the most fundamental antecedent to effective asthma management. Nonetheless, the adequacy and effectiveness of current methods of symptom self-monitoring have been challenged due to the individuals’ fallible symptom perception, poor adherence, and inadequate technique. Recognition of these limitations led to the development of an innovative device that can facilitate continuous and accurate monitoring of asthma symptoms with minimal disruption of daily routines, thus increasing acceptability to adolescents.
The objectives of this study were to: (1) describe the development of a novel symptom monitoring device for teenagers (teens), and (2) assess their perspectives on the usability and acceptability of the device.
Adolescents (13-17 years old) with and without asthma participated in the evolution of an automated device for asthma monitoring (ADAM), which comprised three phases, including development (Phase 1, n=37), validation/user acceptability (Phase 2, n=84), and post hoc validation (Phase 3, n=10). In Phase 1, symptom algorithms were identified based on the acoustic analysis of raw symptom sounds and programmed into a popular mobile system, the iPod. Phase 2 involved a 7 day trial of ADAM in vivo, and the evaluation of user acceptance using an acceptance survey and individual interviews. ADAM was further modified and enhanced in Phase 3.
Through ADAM, incoming audio data were digitized and processed in two steps involving the extraction of a sequence of descriptive feature vectors, and the processing of these sequences by a hidden Markov model-based Viterbi decoder to differentiate symptom sounds from background noise. The number and times of detected symptoms were stored and displayed in the device. The sensitivity (true positive) of the updated cough algorithm was 70% (21/30), and, on average, 2 coughs per hour were identified as false positive. ADAM also kept track of the their activity level throughout the day using the mobile system’s built in accelerometer function. Overall, the device was well received by participants who perceived it as attractive, convenient, and helpful. The participants recognized the potential benefits of the device in asthma care, and were eager to use it for their asthma management.
ADAM can potentially automate daily symptom monitoring with minimal intrusiveness and maximal objectivity. The users’ acceptance of the device based on its recognized convenience, user-friendliness, and usefulness in increasing symptom awareness underscores ADAM’s potential to overcome the issues of symptom monitoring including poor adherence, inadequate technique, and poor symptom perception in adolescents. Further refinement of the algorithm is warranted to improve the accuracy of the device. Future study is also needed to assess the efficacy of the device in promoting self-management and asthma outcomes.
PMCID: PMC4114416  PMID: 25100184
asthma; adolescents; symptom monitoring; symptom algorithm; mobile device
6.  Cost-Effectiveness of the School-Based Asthma Therapy (SBAT) Program 
Pediatrics  2013;131(3):e709-e717.
Impoverished urban children suffer disproportionately from asthma and underuse preventive asthma medications. The objective of this study was to examine cost-effectiveness (CE) of the School-Based Asthma Therapy (SBAT) program compared with usual care (UC).
The analysis was based on the SBAT trial, including 525 children aged 3 to 10 years attending urban preschool or elementary school who were randomized to either UC or administration of 1 dose of preventive asthma medication at school by the school nurse each school day. The primary outcome was the mean number of symptom-free days (SFDs). The impact of the intervention on medical costs was estimated by using parent-reported child health services utilization data and average national reimbursement rates. We estimated the cost of running the program using wages for program staff. Productivity costs were estimated by using value of parent lost time due to child illness. CE of the SBAT program compared with UC was evaluated based on the incremental CE ratio.
The health benefit of the intervention was equal to ∼158 SFD gained per each 30-day period (P < .05) per 100 children. The programmatic expenses summed to an extra $4822 per 100 children per month. The net saving due to the intervention (reduction in medical costs and parental productivity, and improvement in school attendance) was $3240, resulting in the incremental cost-savings difference of $1583 and CE of $10 per 1 extra SFD gained.
The SBAT was effective and cost-effective in reducing symptoms in urban children with asthma compared with other existing programs.
PMCID: PMC3581846  PMID: 23400614
randomized trial; cost-effectiveness; asthma; minority children; urban; preventive medicine
7.  Preventive Asthma Care Delivery in the Primary Care Office: Missed Opportunities for Children with Persistent Asthma Symptoms 
Academic pediatrics  2013;13(2):98-104.
To describe which NHLBI preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity.
We approached children (2-12yo) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit.
We identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009-January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs. non-asthma visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (OR .34 [95%CI .14-.84]), trigger reduction discussion (.39[.19-.82]), recommendation of follow-up (.40[.19-.87]), and receipt of action plan (.37[.16-.86]).
Many children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.
PMCID: PMC3602410  PMID: 23294977
asthma; childhood; severity; prevention; primary care
8.  Implementation of a community-based secondhand smoke reduction intervention for caregivers of urban children with asthma: process evaluation, successes and challenges 
Health Education Research  2012;28(1):141-152.
Many children, including those with asthma, remain exposed to secondhand smoke. This manuscript evaluates the process of implementing a secondhand smoke reduction counseling intervention using motivational interviewing (MI) for caregivers of urban children with asthma, including reach, dose delivered, dose received and fidelity. Challenges, strategies and successes in applying MI are highlighted. Data for 140 children (3–10 years) enrolled in the School Based Asthma Therapy trial, randomized to the treatment condition and living with one or more smoker, were analyzed. Summary statistics describe the sample, process measures related to intervention implementation, and primary caregiver (PCG) satisfaction with the intervention. The full intervention was completed by 79% of PCGs, but only 17% of other smoking caregivers. Nearly all (98%) PCGs were satisfied with the care study nurses provided and felt the program might be helpful to others. Despite challenges, this intervention was feasible and well received reaching caregivers who were not actively seeking treatment for smoking cessation or secondhand smoke reduction. Anticipating the strategies required to implement such an intervention may help promote participant engagement and retention to enhance the program’s ultimate success.
PMCID: PMC3549585  PMID: 22717938
9.  Depression among Caregivers of Children with Asthma and its Impact on Communication with Health Care Providers 
Public health  2012;126(12):1051-1057.
Caregiver depression is common, can negatively influence one's ability to communicate with healthcare providers, and may hinder appropriate care for children with asthma.
To evaluate the impact of caregiver depression on communication and self-efficacy in interactions about asthma with their child's physician.
Study Design
Cross sectional analysis using data from the Prompting Asthma Intervention in Rochester–Uniting Parents and Providers study.
We enrolled caregivers of children (2–12 yrs) with persistent asthma prior to their healthcare visit. Caregivers were interviewed via telephone after the visit to assess depression, self-efficacy, and provider communication at the visit. Caregiver depression was measured using the Kessler Psychological Distress scale. We assessed caregiver self-efficacy using items from the Perceived Efficacy in Patient Physician Interactions scale; caregivers rated their confidence for each item (range 0–10). We also inquired about how well the provider communicated regarding the child’s asthma care. Bivariate and multivariate analyses were used.
We interviewed 195 caregivers (response rate 78%; 41% Black, 37% Hispanic), and 30% had depressive symptoms. Caregiver rating of provider communication did not differ by depression. Most caregivers reported high self-efficacy in their interactions with providers; however depressed caregivers had lower scores (8.7 vs. 9.4,p=.001) than non-depressed caregivers. Further, depressed caregivers were less likely to be satisfied with the visit (66% vs. 83%,p=.014), and to feel all of their needs were met (66% vs. 85%,p=.007). In multivariate analyses, depressed caregivers were >2× more likely to be unsatisfied with the visit and to have unmet needs compared to non-depressed caregivers.
Depressed caregivers of children with asthma report lower confidence in interactions with providers about asthma and are less likely to feel that their needs are met at a visit. Further study is needed to determine the best methods to communicate with and meet the needs of these caregivers.
PMCID: PMC3578509  PMID: 23102501
asthma; caregiver depression; health care provider; communication
10.  The School-Based Preventive Asthma Care Trial: Results of a Pilot Study 
The Journal of pediatrics  2012;161(6):1109-1115.e1.
To test the feasibility and preliminary effectiveness of the SB-PACT program, which includes directly observed therapy of preventive asthma medications in school facilitated by web-based technology for systematic symptom screening, electronic report generation, and medication authorization from providers.
Study design
We conducted a pilot randomized trial of SB-PACT vs. usual care with 100 children (ages 3-10yrs) from 19 inner-city schools in Rochester, NY. Outcomes were assessed longitudinally by blinded interviewers. Analyses included bivariate statistics and linear regression models, adjusting for baseline symptoms.
99 subjects had data for analysis. We screened all children using the web-based system, and 44/49 treatment children received directly observed therapy as authorized by their providers. Treatment children received preventive medications 98% of the time they were in school. Over the school year, children in the treatment group experienced nearly 1 additional symptom-free day/two weeks vs. usual care (11.33 vs. 10.40,p=.13). Treatment children also experienced fewer symptom nights (1.68 vs. 2.20,p=.02), days requiring rescue medications (1.66 vs. 2.44,p=.01) and days absent from school due to asthma (.37 vs. .85,p=.03) compared with usual care. Further, treatment children had a greater decrease in exhaled nitric oxide (−9.62 vs. −.39,p=.03), suggesting reduction in airway inflammation.
The SB-PACT intervention demonstrated feasibility and improved outcomes across multiple measures in this pilot study. Future work will focus on further integration of preventive care delivery across community and primary care systems.
PMCID: PMC3470823  PMID: 22785264
asthma; schools; technology; urban; preventive care
11.  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
12.  The Role of Parent Health Literacy Among Urban Children with Persistent Asthma 
Patient education and counseling  2009;75(3):368-375.
Health literacy (HL) affects adult asthma management, yet less is known about how parent HL affects child asthma care.
To examine associations between parent HL and measures related to child asthma.
Parents of 499 school-age urban children with persistent asthma in Rochester, New York completed home interviews. Measures: The Rapid Estimate of Adult Literacy in Medicine for parent HL; NHLBI criteria for asthma severity, and validated measures of asthma knowledge, beliefs, and experiences. Analyses: Bivariate and multivariate analyses of associations between parent HL measures related to child asthma.
Response rate: 72%, mean child age: 7.0 years. Thirty-two percent had a Hispanic parent; 88% had public insurance. Thirty-three percent had a parent with limited HL. Low parent HL was independently associated with greater parent worry parent perception of greater asthma burden, and lower parent-reported quality of life. Measures of health care use (e.g., emergency care, preventive medicines) were not associated with parent HL.
Parents with limited HL worried more and perceived greater overall burden from the child’s asthma, even though reported health care use did not vary.
Practice Implications
Improved parent understanding and provider-parent communication about child asthma could reduce parent-perceived asthma burden, alleviate parent worry, and improve parent quality of life.
PMCID: PMC3712512  PMID: 19233588
Health Literacy; asthma; asthma care; child health; child asthma; health behavior; health beliefs; provider-patient communication; pediatric care; medical care; REALM; poverty; low-income; PACQOL; asthma burden; urban children
13.  Working toward a Sustainable System of Asthma Care: Development of the School-Based Preventive Asthma Care Technology (SB-PACT) Trial 
The Journal of Asthma  2012;49(4):395-400.
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.
PMCID: PMC3381057  PMID: 22455402
asthma; school-based; technology; sustainability; preventive care
14.  Randomized Controlled Trial to Improve Care for Urban Children With Asthma 
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.
PMCID: PMC3600609  PMID: 21383275
15.  Nocturnal Asthma Symptoms and Poor Sleep Quality among Urban School Children with Asthma 
Academic pediatrics  2011;11(6):493-499.
To describe nocturnal asthma symptoms among urban children with asthma and assess the burden of sleep difficulties between children with varying levels of nocturnal symptoms.
We analyzed baseline data from 287 urban children with persistent asthma (ages 4–10) enrolled in the School-Based Asthma Therapy trial; Rochester, NY. Caregivers reported on nocturnal asthma symptoms (# nights/2 weeks with wheezing or coughing), parent quality of life (Juniper’s PACQLQ), and sleep quality using the validated Children’s Sleep Habits Questionnaire. We used bivariate and multivariate statistics to compare nocturnal asthma symptoms with sleep quality/quantity and quality of life.
Most children (mean age 7.5yrs) were Black (62%); 74% had Medicaid. Forty-one percent of children had intermittent nocturnal asthma symptoms, 23% mild persistent, and 36% moderate to severe. Children’s average total sleep quality score was 51 (range 33–99) which is above the clinically significant cut-off of 41, indicating pervasive sleep disturbances among this population. Sleep scores were worse for children with more nocturnal asthma symptoms compared to those with milder symptoms on total score, as well as several subscales including night wakings, parasomnias, and sleep disordered breathing (all p<.03). Parents of children with more nocturnal asthma symptoms reported their child having fewer nights with enough sleep in the past week (p=.018) and worse parent quality of life (p<.001).
Nocturnal asthma symptoms are prevalent in this population, and are associated with poor sleep quality and worse parent quality of life. These findings have potential implications for understanding the disease burden of pediatric asthma.
PMCID: PMC3481184  PMID: 21816697
asthma; childhood; symptoms; sleep; quality of life; smoke
16.  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
17.  Health Literacy and Sources of Health Information for Caregivers of Urban Children with Asthma 
Clinical Pediatrics  2011;51(3):267-273.
Little is known about the resources urban caregivers of children with asthma use to obtain health information. We analyzed data for 304 families of children with persistent asthma to describe: 1) sources of health information, 2) access and use of Internet resources, and 3) the association between caregiver’s health literacy (HL) and use of health information sources. Overall, 37% of caregivers had Limited HL. Most families received health information from: a health care professional (94%); written sources (51%); family/friends (42%); non-print media (34%); and Internet (30%). Less than ½ of caregivers had access to Internet at home, but 73% reported Internet use in the past year. Caregivers with Adequate HL were more likely to obtain information from multiple sources, and to use and have access to the Internet. Our results suggest that HL is associated with where caregivers obtain health information for their children and their use of the Internet.
PMCID: PMC3295538  PMID: 21911409
asthma; inner-city; health literacy; health information; Internet
18.  Adolescents’ Perception of Asthma Symptoms and Health Service Utilization 
Pediatric asthma is accountable for a substantial use of health care services. The purpose of this study was to systemically examine the extent to which inaccurate perception of asthma symptoms is associated with the use of health care services.
This exploratory study included 126 adolescents with asthma, aged between 13–20 years. Subjects were classified as having inaccurate symptom perception (IG), well controlled, accurate symptom perception (WCA), and poorly-controlled accurate symptom perception (PCA). These groups were compared with respect to health care utilization including emergency department (ED) visits, hospitalization and office visits and school absenteeism in the past 3 months.
More adolescents in the inaccurate group had at least one hospitalization compared to adolescents in the PCA or WCA groups (23.1% vs. 11.1% vs. 2.6% respectively). A similar trend was seen for emergency department visits. Compared to WCA group, adolescents in the inaccurate group were nearly 9 times more likely to have been hospitalized, 3.4 times more likely to have visited an emergency department (ED), and 4 times more likely to have missed school days.
Adolescents with inaccurate symptom perception are more likely to have hospitalizations, ED visits, and missed days from school as compared to those with accurate perceptions. The findings underscore the importance of screening for perceptual accuracy of asthma symptoms and call for interventions promoting accurate symptom assessment in adolescents with asthma to assure appropriate care.
PMCID: PMC3060703  PMID: 21320682
19.  Dependence on Emergency Care among Young Adults in the United States 
Young adults have a high prevalence of many preventable diseases and frequently lack a usual source of ambulatory care, yet little is known about their use of the emergency department.
To characterize care provided to young adults in the emergency department.
Cross-sectional analysis of visits from young adults age 20 to 29 presenting to emergency departments (N = 17,048) and outpatient departments (N = 14,443) in the National Hospital Ambulatory Medical Care Survey and National Ambulatory Medical Care Survey.
Visits to the emergency department compared to ambulatory offices.
Emergency department care accounts for 21.6% of all health care visits from young adults, more than children/adolescents (12.6%; P < 0.001) or patients 30 years and over (8.3%; P < 0.001). Visits from young adults were considerably more likely to occur in the emergency department for both injury-related and non-injury-related reasons compared to children/adolescents (P < 0.001) or older adults (P < 0.001). Visits from black young adults were more likely than whites to occur in the emergency department (36.2% vs.19.2%; P < 0.001) rather than outpatient offices. The proportion of care delivered to black young adults in the emergency department increased between 1996 and 2006 (25.9% to 38.5%; P = 0.001 for trend). In 2006, nearly half (48.5%) of all health care provided to young black men was delivered through emergency departments. The urgency of young adult emergency visits was less than other age groups and few (4.7%) resulted in hospital admission.
A considerable amount of care provided to young adults is delivered through emergency departments. Trends suggest that young adults are increasingly relying on emergency departments for health care, while being seen for less urgent indications.
PMCID: PMC2881978  PMID: 20306149
emergency care; ambulatory care; young adults
20.  Motivation to Quit Smoking among Parents of Urban Children with Asthma 
Patient education and counseling  2009;79(2):152-155.
To identify factors associated with motivation to quit smoking among parents of urban children with asthma.
We analyzed data from parents who smoke and had a child enrolled in the School-Based Asthma Therapy trial. We assessed asthma symptoms, children's cotinine, and parent smoking behaviors. Motivation to quit smoking was assessed by a 10-point continuous measure (1=not at all motivated; 10=very motivated).
209 parents smoked (39% of sample), and children's mean cotinine was 2.48 ng/ml. Motivation to quit was on average 6.9, and 47% of parents scored ≥8 on the scale. Parents who believed their child's asthma was not under good control, and parents who strongly agreed their child's asthma symptoms would decrease if they stopped smoking had higher motivation to quit compared to their counterparts (p <.05). In a multivariate analysis, parents who believed their child's asthma was not under control had more than twice the odds of reporting high motivation to quit.
Parents' perception of the risks of smoking to their child with asthma is associated with motivation to quit.
Practice Implications
Raising awareness about the effect of smoking and quitting on children's asthma might increase motivation to quit among parents.
PMCID: PMC2856779  PMID: 19796913
Asthma; parents; children; smoking cessation; motivation; environmental tobacco smoke
21.  Sleep-Disordered Breathing and Behaviors of Inner-City Children with Asthma 
Pediatrics  2009;124(1):218-225.
To explore the relationship between sleep-disordered breathing (SDB) and behavioral problems among inner-city children with asthma.
Patients and Methods
We examined data for 194 children (age 4–10 yrs) who were enrolled in a school-based asthma intervention program (response rate: 72%). SDB was assessed using the Sleep-Related Breathing Disorder (SRBD) questionnaire that contains 3 subscales: snoring, sleepiness, and attention/hyperactivity. For the current study, we modified the SRBD by removing the 6 attention/hyperactivity items. A sleep score of >.33 was considered indicative of SDB. To assess behavior, caregivers completed the Behavior Problem Index (BPI) which includes 8 behavioral subdomains. We conducted bivariate analyses and multiple linear regression to determine the association of SDB with BPI scores.
The majority of children (mean age 8.2 yrs) were male (56%), African American (66%), and insured by Medicaid (73%). Overall, 33% of children experienced SDB. In bivariate analyses, children with SDB had significantly higher (worse) behavior scores compared to children without SDB on total BPI (13.7 vs 8.8, p<.001), externalizing (9.4 vs 6.3, p<.001), internalizing (4.4 vs 2.5, p<.001), anxious/depressed (2.4 vs 1.3, p<.001), headstrong (3.2 vs 2.1, p<.001), antisocial (2.3 vs 1.7, p=.013), hyperactive (3.0 vs 1.8, p<.001), peer conflict (.74 vs .43, p=.011), and immature (2.0 vs 1.5, p=.001). In multiple regression models adjusting for several important covariates, SDB remained significantly associated with total BPI, externalizing, internalizing, anxious/depressed, headstrong, and hyperactive behaviors. Results were consistent across SBD subscales (snoring, sleepiness).
We found that poor sleep was independently associated with behavior problems in a large proportion of urban children with asthma. Systematic screening for SDB in this high-risk population might help to identify children who would benefit from further intervention.
PMCID: PMC2704979  PMID: 19564303
childhood asthma; inner-city; behavior; sleep-disordered breathing
22.  Screen Time Use Among Urban Children with Asthma 
Academic pediatrics  2009;9(1):60-63.
To describe screen time use and factors related to screen time among urban children with persistent asthma.
Patients and Methods
We analyzed data for 224 children (3–10 years) with persistent asthma. Parents reported on children’s asthma severity, screen time use, and family practices regarding screen time. We asked parents: “On weekdays [and weekends] on average, over a 24 hour period, how many hours of screen time does your child have?” Parents also reported activity limitation due to asthma, and activities their child engaged in during times of activity limitation.
Most children were male (58%), Black (65%), and had Medicaid (74%); average screen time was 3.4 hours per day. Most parents (74%) reported that their child had >2 hours of screen time per day and 1/3 were concerned that their child had too much screen time. Many children (63%) engaged in screen time activities during activity limitation due to asthma. Children who needed to slow down or stop normal activity due to asthma had more screen time compared to children who didn’t need to slow down (3.51hrs vs. 2.44hrs, p=.02). Additionally, children who engaged in screen time activities during times of physical limitation had more screen time compared to children who engaged in other activities (3.67hrs vs. 2.99hrs, p=.01).
We found that urban children with asthma, particularly those with activity limitation, have excessive use of screen time. Strategies are needed to avoid activity limitation by improving asthma care and to empower families with alternate strategies to avoid excess screen time.
PMCID: PMC2663806  PMID: 19329093
Asthma; Activity limitation; Screen time; TV
23.  Improving Care for Urban Children with Asthma: Design and Methods of the School-Based Asthma Therapy (SBAT) Trial 
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.
PMCID: PMC2605580  PMID: 18446591
asthma; children; preventive care; schools; environmental tobacco smoke; adherence
24.  Environmental Tobacco Smoke and Behaviors of Inner-City Children With Asthma 
To explore the relationship between environmental tobacco smoke (ETS) exposure and behavior among inner-city children with significant asthma.
We analyzed baseline data for 200 children 4 to 10 years old who were enrolled in an asthma program. Environmental tobacco smoke exposure was measured by the child’s salivary cotinine level. Caregivers completed the 28-item Behavior Problem Index (BPI). Positive responses were summed for a total BPI score, and children with scores >14 were considered to have significant behavior problems. We conducted Student t tests and multivariate regression analyses to determine the association of children’s cotinine levels with BPI scores.
Overall, 56% of children were male, 65% were black, and 72% had Medicaid. Mean cotinine level was 1.47 ng/mL. Overall, 30% of children had total BPI scores >14. Children with cotinine values >1.47 ng/mL had significantly higher scores compared with children with lower cotinine values on total BPI (12.5 vs 10.2), as well as externalizing (9.0 vs 7.2), antisocial (2.3 vs 1.7), and immature (2.1 vs 1.6) subscales. In a multivariate model, log cotinine remained independently associated with externalizing (P = .04), headstrong (P = .04), and antisocial behavior (P = .04).
Cotinine levels are independently associated with problem behaviors among this sample of urban children with asthma.
PMCID: PMC2597107  PMID: 18922501
behavior; childhood asthma; environmental smoke exposure; inner-city
25.  Screening for Environmental Tobacco Smoke Exposure among Inner City Children with Asthma 
Pediatrics  2008;122(6):1277-1283.
Environmental tobacco smoke (ETS) causes increased morbidity among children with asthma, however pediatricians do not consistently screen and counsel families of asthmatic children regarding ETS. An index score based on parent report of exposure could help providers efficiently screen for ETS.
1) To develop an index measure of ETS based on parent self-report of smoking behaviors; 2) To determine whether the index score is associated with children’s present and future cotinine levels.
Data were drawn from a community intervention for inner-city children with persistent asthma (n=226, response rate 72%). Measures of child salivary cotinine and parent self-reported ETS-related behaviors were obtained at baseline and 7–9 months later. To develop the index score, we used a 15-fold cross-validation method on 70% of our data that considered combinations of smoke exposure variables, controlling for demographics. We chose the most parsimonious model that minimized the mean square predictive error. The resulting index score included primary caregiver smoking and home smoking ban status. We validated our model on the remaining 30% of data. ANOVA and multivariate analyses were used to determine the association of the index score with children’s cotinine levels.
54% of asthmatic children lived with ≥1 smoker and 51% of caregivers reported a complete home smoking ban. The children’s mean baseline cotinine was 1.55ng/ml (range 0.0–21.3). Children’s baseline and follow-up cotinine levels increased as scores on the index measure increased. In a linear regression, the index score was significantly and positively associated with children’s cotinine measurements at baseline (p<.001, model R2=.37) and 7–9 months later (p<.001, R2=.38).
An index measure with combined information regarding primary caregiver smoking and household smoking restrictions helps to identify asthmatic children with the greatest exposure to ETS, and can predict children who will have elevated cotinine levels 7–9 months later.
PMCID: PMC2597221  PMID: 19047246
Environmental tobacco smoke; asthma; children; primary care; screening

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