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AbstractObjectiveMethodsResultsConclusionCaregivers of children with asthma can become overwhelmed by the burden of care provision. Guided by the socioecological framework, we examined individual and system-level factors associated with caregiver health-related quality of life (HRQoL) among preschool children (aged two to six years) enrolled in a multilevel home- and school-based asthma educational intervention in Baltimore, Maryland.The primary outcome was caregiver HRQoL measured at baseline and six months. Independent variables were baseline individual-level factors (caregiver’s health literacy, self-efficacy to manage asthma, and depressive symptoms) and system-level factors (barriers to asthma care measured in five subdomains—pragmatics, health knowledge and beliefs, expectations, skills, and marginalization—and neighborhood social cohesion). Multiple regression models were used to assess the association between baseline individual and system-level factors and caregiver HRQoL at baseline and six-month follow-up adjusting for the child’s asthma control, caregiver’s age, household income, and study arm assignment/intervention.398 caregivers completed the baseline survey and 328 (82%) completed the six-month follow-up survey. In the adjusted multiple regression model, lower caregiver’s health literacy and higher barriers to asthma care related to pragmatics were significantly associated with lower caregiver HRQoL at baseline (b = 0.38, 95% CI, 0.15–0.61, p = .002; and b = 0.01, 95% CI, 0.004–0.02, p < .001, respectively). The results were similar at the six-month follow-up.Caregiver health literacy and barriers to asthma care related to pragmatics and skills were found to be important determinants of asthma caregiver HRQoL. Addressing these factors may improve the quality of life among caregivers of preschool children with asthma. [ABSTRACT FROM AUTHOR]

Objective: We are yet to understand how widely parents seek asthma medication management information for their children, how they are used for health information, how parents engage with them and their influence on parent's decision-making. This study aimed to gauge the current level of asthma knowledge and skills of parents of children with asthma and gain insight into who and what influences their child's asthma medication management decisions. Method: Social network theory was used to map parents' asthma networks and identify the level of influence of each individual/resource nominated. Parents of children with asthma (aged 4–18 years) were interviewed, completed an asthma network map, questionnaires and an inhaler technique assessment. Results: Twenty-six parents participated and had significant gaps in asthma knowledge and inhaler technique skills. The asthma networks of participants ranged from two to ten individuals/resources, with an average number of five. The most commonly nominated individual/resource was general practitioners followed by family members and the internet. Professional connections represented 44% of individuals/resources in networks, personal connections 42% and impersonal connections 14%. When parents were asked about how influential individuals/resources were, professional connections represented 53% of parents influences, personal connections 36% and impersonal connections 11%. Conclusion: This study highlights the priority and co-influence of non-medical sources of information/support on parent's behaviors and decision-making with regards to their child's asthma medicine taking. In further understanding the complexities surrounding these connections and relationships, HCPs are better positioned to assist parents in addressing their needs and better supporting them in the management of their child's asthma. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to evaluate the mediating role of perceptions of primary care (PC) on the association between depression and PC clinic attendance among caregivers of children with asthma. In adults, depression is associated with lower PC clinic attendance and ∼25% of mothers presenting to a pediatric PC clinic will screen positive for depression. Adults' perceptions about their medical care mediate the depression-clinic attendance relation, but this has not been tested in children or in an asthma population. Methods: This is a secondary prospective data analysis of 141 caregivers of Head Start children diagnosed with asthma, offered an intervention to reduce barriers to PC. Caregivers rated their depressive symptoms and perceptions of PC (access, provider contextual knowledge, and continuity of care) at baseline. PC clinic attendance was tracked prospectively for 6-months. Results: At baseline, 26% of caregivers screened positive for depression. Within 6-months, 66% of children attended a PC appointment. A positive depression screen was not associated with PC attendance ( p = 0.07) or continuity of care ( p = 0.98) but was inversely associated with perceptions of both access ( p = 0.03) and provider contextual knowledge ( p = 0.02). Though the total indirect effect was not significant, the specific indirect effect of depression on PC attendance through access was significant (95% CI: 0.01, 0.68). Conclusions: Providing tangible resources to reduce barriers to PC without addressing perceptions of access may not sufficiently improve PC clinic attendance in pediatric asthma. Screening caregivers for depression may identify families requiring targeted interventions to improve their perceptions of access. [ABSTRACT FROM AUTHOR]

Objective: We sought to understand if pediatrician characteristics and asthma assessment and treatment varied in association with the proportion of African-American and Latino children in the pediatrician's practice. Methods: We conducted a cross-sectional survey of 500 American Academy of Pediatrics members between November 2005 and May 2006. Standardized vignettes were used to test how different indicators of a patient's asthma status affect pediatrician asthma assessments and recommendations. Linear and logistic regression models were used to examine the association of pediatrician assessments and treatment recommendations for these vignettes, respectively, with the proportion of reported African-American and Latino children seen in their practice. Results: There were 270 respondents (response rate = 54%). Based on pediatrician-reported percentage of minority patients, there were no differences in board certification status, recognition of poorly controlled asthma nor in the likelihood of appropriately increasing long-term controller medications to treat poorly controlled asthma ( p > 0.05 for all analyses). Conclusions: Caring primarily for minority children by AAP pediatricians appears unrelated to training qualifications or in their reported knowledge of how to appropriately assess and treat asthma. Therefore, studies of asthma care disparities should focus on understanding the knowledge-base of non-AAP pediatric providers who care for minority populations and exploring other potential contributory provider-level factors (e.g. communication skills). [ABSTRACT FROM AUTHOR]

Background: Asthma morbidity and mortality rates are high among young inner-city children. Lack of routine primary care provider visits, poor access to care, and poor patient-physician communication might be contributing factors. Objective: This study evaluated the effects of providing Breathmobile services only, a Facilitated Asthma Communication Intervention (FACI) only, or both Breathmobile plus FACI on asthma outcomes relative to standard care. Methods: Children with asthma (n = 322; mean age, 4 years; 53% male; 97% African American) were recruited from Head Start programs in Baltimore City and randomized into 4 groups. Outcome measures included symptom-free days (SFDs), urgent care use (emergency department visits and hospitalizations), and medication use (courses of oral steroids and proportion taking an asthma controller medication), as reported by caregivers at baseline, 6-month, and 12-month assessments. Generalized estimating equations models were conducted to examine the differential treatment effects of the Breathmobile and FACI compared with standard care. Results: Children in the combined treatment group (Breathmobile plus FACI) had an increase of 1.7 (6.6%) SFDs that was not maintained at 12 months. In intent-to-treat analyses the FACI-only group had an increase in the number of emergency department visits at 6 months, which was not present at 12 months or in the post hoc as-treated analyses. No significant differences were found between the intervention groups compared with those receiving standard care on all other outcome measures. Conclusions: Other than a slight improvement in SFDs at 6 months in the Breathmobile plus FACI group, the intervention components did not result in any significant improvements in asthma management or asthma morbidity. [ABSTRACT FROM AUTHOR]

Background: Information comparing subjective and objective measurements of adherence to study medications and the effects of adherence on treatment-related differences in asthma clinical trials are limited. Objective: We sought to compare subjective and objective measurements of children’s adherence to inhaled corticosteroids or placebo and to determine whether adherence to study medications modified treatment-related differences in outcomes. Methods: In an ancillary study conducted in 3 of 8 Childhood Asthma Management Program Clinical Centers, adherence was assessed by using self-reported and objective data in 5- to 12-year-old children with mild or moderate asthma who were randomly assigned to 200 μg of inhaled budesonide twice per day (n = 84) or placebo (n = 56) for 4 years. The κ statistic was used to evaluate agreement between self-reported adherence (daily diary cards) and objectively measured adherence (number of doses left in study inhalers). Multivariable analyses were used to determine whether adherence to study treatment modified treatment-related differences in outcomes. Results: Adherence of less than 80% was seen in 75% of 140 children when adherence was measured objectively but only in 6% of children when measured by means of self-report. There was poor agreement between objective and subjective measurements of adherence of at least 80% (κ = 0.00; 95% CI, −0.05 to 0.04); self-reported adherence over the 4-year period generally overestimated objectively measured adherence (93.6% vs 60.8%, P < .0001). There was little evidence to indicate that adherence modified treatment-related differences in outcomes. Conclusion: Researchers should use objective rather than self-reported adherence data to identify clinical trial participants with low levels of adherence to study treatment. [ABSTRACT FROM AUTHOR]

Background. Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico. Objectives. Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children. Methods. Children 3-18 years old with at least one service claim [outpatient, hospitalization, or emergency department (ED) visit] for asthma or reactive airway disease from 2005 to 2006 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for anti-inflammatory controller medication (CM). Results. Private insurance families ( n = 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families ( n = 13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, emergency room use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of β-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect. Conclusion. Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under-treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits. Capsule summary. A disparity exists in asthma medication dispensing between children with public insurance compared with those with private insurance under a Managed Care Medicaid system in Puerto Rico. If asthma disparities in medication dispensing are to be reduced, then a better understanding of the complex ways in which multiple variables related to the health care system policies, socioeconomic factors, family and provider interactions, as well as the relative weight that each one contributes to the observed inequalities is needed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Adherence to inhaled steroid regimens for asthma is poor in adults and children. Although it is assumed that nonadherence contributes to morbidity in older adolescents, investigation is limited. Objective: We sought to describe adherence to preventive asthma medications and explore relevant beliefs and attitudes in older urban adolescents, including their ideas for improving adherence. Methods: Quantitative and qualitative methods were used to collect data from a convenience sample of adolescents with asthma previously prescribed fluticasone/salmeterol (F/S). Two semistructured face-to-face interviews were conducted 1 month apart and analyzed for themes. F/S use was electronically monitored between visits and calculated as the number of actuations divided by the number of inhalations prescribed. Results: Forty participants, (15-18 years of age, 19 female subjects, 30 black/African American subjects, 11 Medicaid-insured subjects, and 24 previously hospitalized for asthma) with a median FEV1 of 98% of predicted value (range, 67% to 127%) had median adherence of 43% (range, 4% to 89%). Adherence was not associated with FEV1 or emergency department visits. Themes emerged from interviews as follows. Teens (1) take F/S inconsistently; (2) believe F/S is “supposed to help me breathe”; (3) dislike its taste; (4) are “too busy” and “forget”; and (5) recommend “reminder” solutions to poor adherence. Twenty percent believed that taking F/S was unnecessary, and another 18% expressed ambivalence about its benefits. Conclusion: Adherence was poor. Examining and acknowledging health beliefs of older teens in the context of their complicated lives might facilitate discussions about self-management. [Copyright &y& Elsevier]

Background: Although mouse allergen exposure is common in inner-city homes, little is known about the relationships between exposure and humoral immune responses to mouse allergen in this population. Objective: To examine relationships between mouse allergen exposure and allergen-specific IgE and IgG responses in inner-city children with asthma. Methods: Inner-city children with asthma underwent skin testing and venipuncture for determination of mouse allergen–specific IgE and IgG levels. Settled dust samples were collected from their homes for allergen analysis. Results: The study population (n = 112) was predominantly African American (92%) with a mean age of 4.4 years. The prevalence rate of mouse sensitization was 25% and did not consistently increase with increasing Mus m 1 levels. Instead, the prevalence rate was lowest among those exposed to <2 μg/g, increased among those exposed to 2-7.9 μg/g and 8-29.9 μg/g, and then decreased among participants exposed to >29.9 μg/g (14%, 20%, 40%, and 28%, respectively). Similarly, the prevalence rates of mouse allergen–specific IgG and IgG4 did not increase across increasing exposure categories. Mouse allergen–specific IgG and IgG4 were strongly associated with IgE sensitization (odds ratios [95% CI], 82.8 [20.5-334.4] and 50.4 [14.0-181.7], respectively). Conclusion: High-level exposure to mouse allergen in children may be associated with attenuated humoral responses of all isotypes rather than selective attenuation of IgE. Clinical implications: Protection against allergic sensitization by high-dose allergen exposure may not be mediated by preferential production of IgG over IgE. [Copyright &y& Elsevier]

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

Background: The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines include recommendations on how to improve the quality of care for asthma. Objective: To identify barriers to physician adherence to the NHLBI guidelines. Design: Cross-sectional survey. Participants: A national random sample of 829 primary care pediatricians. Main Outcome Measures: Self-reported adherence to 4 components of the NHLBI guidelines (steroid prescription, instructing peak flow meter use, screening and counseling patients with asthma for smoking, and screening and counseling parents for smoking). We also collected information on physician demographics, practice characteristics, and possible barriers to adherence. We defined adherence as following a guideline component more than 90% of the time. Results: The response rate was 55% (456/829). Most of the responding pediatricians were aware of the guidelines (88%) and reported having access to a copy of the guidelines (81%). Self-reported rates of adherence were between 39% and 53% for the guideline components. After controlling for demographics and other barriers, we found that nonadherence was associated with specific barriers for each guideline component: for corticosteroid prescription, lack of agreement (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.2-14.4); for peak flow meter use, lack of self-efficacy (OR, 3.4; 95% CI, 1.9-6.1) and lack of outcome expectancy (OR, 4.7; 95% CI, 2.5-8.9); and for screening and counseling of patients and parents for smoking, lack of self-efficacy (OR, 3.8; 95% CI, 1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectively). Conclusions: Although pediatricians in this sample were aware of the NHLBI guidelines, a variety of barriers precluded their successful use. To improve NHLBI guideline adherence, tailored interventions that address the barriers characteristic of a given guideline component need to be implemented. [ABSTRACT FROM AUTHOR]

Context: Inner-city minority children with asthma use emergency departments (ED) frequently. Objective: To examine whether maternal depressive symptoms are associated with ED use. Design, Setting, and Patients: Baseline and 6-month surveys were administered to mothers of children with asthma in inner-city Baltimore, Md, and Washington, DC. Main Outcome Measures: Use of the ED at 6-month follow-up was examined. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. Results: Among mothers, nearly half reported significant levels of depressive symptoms. There were no demographic or asthma-related differences between the children of mothers with high and low depressive symptoms. However, in bivariate analyses, mothers with high depressive symptoms were 40% (prevalence ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6; P=.04) more likely to report taking their child to the ED. Mothers aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3; P=.001) to report ED use, as were children with high morbidity (PR, 1.9; 95% CI, 1.4-7.1; P=.006). Child age and family income were not predictive of ED use. After controlling for asthma symptoms and mother's age, mothers with depressive symptoms were still 30% more likely to report ED use. Conclusions: Depression is common among inner-city mothers of children with asthma. Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors of reports of ED visits. Identifying and addressing poor psychological adjustment in mothers may reduce unnecessary ED visits and optimize asthma management among inner-city children. [ABSTRACT FROM AUTHOR]

In this article we discuss studies of individualized and community-based interventions for control of asthma in children. We Posit that successful programs share 8 common characteristics: (1) recognition of the multiple factors affecting childhood asthma; (2) careful assessment of participants' risk factors and needs; (3) tailoring of program elements to address participants' risk factors and needs; (4) consideration of both physical and social environments; (5) use of sound learning and change theories; (6) family involvement; (7) focus on children with the most serious disease; and (8) selection of delivery venues at which learning can be optimized. Challenges for moving practice and research forward also are presented. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To develop and assess the feasibility of a motivational interviewing (MI) based asthma self-management program for inner-city, African-American, adolescents with asthma. Methods: 37 African-American adolescents (age 10–15 years) recently seen in an inner-city emergency department for asthma and prescribed an asthma controller medication participated in the newly developed program consisting of 5 home visits. Adolescents and their caregivers completed phone-based surveys before and after the intervention. Results: 95% of the adolescents completed all 5 sessions; 89% of caregivers and 76% of adolescents believed other families would benefit from the intervention. Caregivers were more likely to report 100% adherence post-intervention compared to pre-intervention and reported a trend for adolescents taking greater responsibility for their asthma. There were no pre-post-differences in adolescent-reported medication adherence, but adolescents did reported increased motivation and readiness to adhere to treatment. Caregivers and adolescents each reported statistically significant increases in their asthma quality of life. Conclusions: The findings from this pilot study suggest that MI is a feasible and promising approach for increasing medication adherence among inner-city adolescents with asthma and is worthy of further evaluation in a randomized trial. Practice Implications: Incorporating MI into disease management programs may enhance their effectiveness. [Copyright &y& Elsevier]

Objective: Many children with asthma do not take medications as prescribed. We studied parents of children with asthma to define patterns of non-concordance between families’ use of asthma controller medications and clinicians’ recommendations, examine parents’ explanatory models (EMs) of asthma, and describe relationships between patterns of non-concordance and EM. Methods: Qualitative study using semi-structured interviews with parents of children with persistent asthma. Grounded theory analysis identified recurrent themes and relationships between reported medication use, EMs, and other factors. Results: Twelve of the 37 parents reported non-concordance with providers’ recommendations. Three types of non-concordance were identified: unintentional—parents believed they were following recommendations; unplanned—parents reported intending to give controller medications but could not; and intentional—parents stated giving medication was the wrong course of action. Analysis revealed two EMs of asthma: chronic—parents believed their child always has asthma; and intermittent—parents believed asthma was a problem their child sometimes developed. Conclusions: Concordance or non-concordance with recommended use of medications were related to EM''s and family context and took on three different patterns associated with medication underuse. Practice Implications: Efforts to reduce medication underuse in children with asthma may be optimized by identifying different types of non-concordance and tailoring interventions accordingly. [Copyright &y& Elsevier]

Abstract: This paper presents indoor air pollutant concentrations and allergen levels collected from the homes of 100 Baltimore city asthmatic children participating in an asthma intervention trial. Particulate matter (PM), NO2, and O3 samples were collected over 72h in the child''s sleeping room. Time-resolved PM was also assessed using a portable direct-reading nephelometer. Dust allergen samples were collected from the child''s bedroom, the family room, and the kitchen. The mean PM10 concentration, 56.5±40.7μg/m3, is 25% higher than the PM2.5 concentration (), 45.1±37.5μg/m3. PM concentrations measured using a nephelometer are consistent and highly correlated with gravimetric estimates. Smoking households’ average PM2.5 and PM10 concentrations are 33–54μg/m3 greater than those of nonsmoking houses, with each cigarette smoked adding 1.0μm/m3 to indoor PM2.5 and PM10 concentrations. Large percentages of NO2 and O3 samples, 25% and 75%, respectively, were below the limit of detection. The mean NO2 indoor concentration is 31.6±40.2ppb, while the mean indoor O3 concentration in the ozone season was 3.3±7.7ppb. The levels of allergens are similar to those found in other inner cities. Results presented in this paper indicate that asthmatic children in Baltimore are exposed to elevated allergens and indoor air pollutants. Understanding this combined insult may help to explain the differential asthma burden between inner-city and non-inner-city children. [Copyright &y& Elsevier]

The environment is suspected to play an important role in the prevalence and severity of asthma in inner-city children. This paper describes the implementation and baseline data of an inner-city community-based participatory research clinical trial designed to test the effectiveness of a pollutant and allergen control strategy on children''s asthma morbidity. Participants were 100 elementary-school-aged children with asthma, graduates of a school-based asthma education program in East Baltimore. The intervention for half of the randomly assigned families consisted of environmental control education, allergen-proof encasements, pest extermination, and a HEPA air cleaner at the beginning of the study. Controls received the same at the end of the study. Participants visited a clinic for questionnaires, allergy skin testing, spirometry, and blood sample at baseline and 12 months. Home environments, NO2, O3, airborne particulates, and allergens were evaluated at baseline and at 6 and 12 months. Asthma morbidity and adherence was assessed quarterly. Collaboration with the community proved very beneficial in creating a study design and procedures acceptable to an inner-city community. [Copyright &y& Elsevier]

Conclusions. Maternal depressive symptoms were not associated with child asthma morbidity but were associated with a constellation of beliefs and attitudes that may significantly influence adherence to asthma medications and illness management. Identifying and addressing poor psychological adjustment in mothers is important when developing a child's asthma treatment and may facilitate parent-provider communication, med-ication adherence, and asthma management among in-ner- city children. Pediatrics 2004;113:229--237; asthma, maternal depression, medication adherence, attitudes, be-liefs. [ABSTRACT FROM AUTHOR]

Examines the medication used by families in the United States participating in an urban school-based community intervention program in treating children with asthma. National and international guidelines for asthma therapy; Reason for the increase asthma morbidity and mortality among poor, minority children living in United States' inner city; Factors which affect the patterns of asthma medication used by families in the inner city.