Search

Background: Asthma is common among urban school-age children. Though teachers should be prepared to assist children during an asthma attack, studies show they lack self-efficacy in managing asthma....

OBJECTIVE: Physical education (PE) teachers may be the first to assist students with asthma attacks during PE class. This study explores the PE teachers’ perspectives on in-school asthma management and barriers to physical activity (PA) in children with asthma attending urban elementary schools. METHODS: We conducted qualitative semi-structured interviews with 16 PE teachers from 10 Bronx, NY elementary schools. Interviews were recorded, transcribed and independently coded. Content analysis was used to identify 10 major themes common across interviews which were then categorized into 3 domains. RESULTS: Three domains were identified: 1) school procedures and policies for asthma management; 2) role of PE teachers in asthma management; and 3) barriers to PA for students. Most PE teachers were unaware of written procedures for acute asthma management and did not receive asthma-specific training. Many PE teachers expressed confidence regarding asthma management. PE teachers identified students with asthma most commonly through communication with students. The PE teachers utilized various methods to manage asthma but all relied on the nurse to handle acute asthma symptoms. Several barriers to PA were determined, including PE teachers’ unawareness of NYS PE requirements, lack of gym facilities, inclement weather, inconsistent PE class time, asthma diagnosis, and having no asthma inhalers at the nurse’s office. CONCLUSIONS: PE teachers’ perspectives on asthma management may influence the way asthma is handled at school. The results from this study highlight several barriers that can be targeted in future interventions to improve asthma management.

Peaks in childhood asthma symptoms and asthma morbidity occur universally in the fall and late winter/early spring. This study examines whether there is a time of the year best suited to implement environmental interventions to attenuate this pattern.From September 2006 to June 2010, mid-Atlantic inner-city children asthmatics with 1 asthma-related hospitalization (IP) or 2 emergency (ED) visits the year prior to enrollment received 5 in-home self-management education sessions which included multi-trigger avoidance techniques and supplies. Children's daily asthma symptoms were recorded for 12 months by caregivers.One-hundred and thirty-six children (48%) completed 12 months of symptoms diaries. Symptom days were reduced by 4.5 days at 12 months follow-up (p 0.001). Symptom severity improved with a decreased severity score of 29.0 to 7.9 at month 12 (p 0.001). Sixty-one percent of patients with ≥2 ED visits at baseline dropped to 0-1visits (p 0.001). Eighty percent of patients with ≥1 IP visits dropped to 0 visits at 12 months (p 0.001). Patients who received intervention in the summer months had half the average monthly symptoms score (10.8) as those who received intervention in the spring months (20.8). When controlling for environment and morbidity, the summer enrolled group had a significantly lower (p = 0.021) symptom score than those in other seasons.Home self-management/environmental interventions for this cohort appear to have the greatest effect for those receiving the intervention in the summer and fall. The largest impact occurs in the summer cohort. Further studies with a control group are necessary to confirm these findings.

Objective: The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma.During an ED visit for asthma in an inner city hospital ('index visit'), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit.One hundred and ninety-two patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multivariate model, more past ED visits (OR 1.7, 95% CI 1.4, 2.1; p 0.0001) and male gender (OR 2.5, 95% CI 1.2, 5.4; p = 0.02) remained associated with having a repeat ED visit. Most patients had the first repeat ED visit within 30 days and 18 returned within only 7 days. Among all patients with a repeat visit, those who were not hospitalized for the index visit were more likely to have a repeat visit within 7 days (37%) compared to those who were hospitalized (17%) (p = 0.05 in multivariate analysis).Repeat ED visits were prevalent among inner city asthma patients and most occurred shortly after the index visit. The strongest predictors of repeat visits were male gender and more ED visits in the 12 months before the index visit.

Caregivers' asthma health beliefs can impact healthcare decisions. This study aimed to determine whether caregivers with a diagnosis of post-traumatic stress disorder (PTSD) had asthma illness representations less aligned with the professional model of asthma management and whether their children had worse asthma control.Participants were 120 children with asthma (age M = 9.25 ± 1.37) and their caregivers recruited from the Bronx, NY, USA. Participants were Puerto Rican (n = 55), African-American (n = 30), Afro-Caribbean (n = 22), and Mexican (n = 13). Caregivers completed: a psychiatric interview to determine diagnosis of PTSD, anxiety and depressive disorders; the Asthma Illness Representation Scale (AIRS) to assess beliefs about their children's asthma; and the childhood asthma control test (C-ACT).One in five caregivers had PTSD, and these caregivers had lower total AIRS scores, lower scores on the AIRS Emotional Aspects of Medication Use subscale, and the AIRS Nature of Symptoms subscale, indicating illness beliefs less aligned with the professional model. Caregivers with PTSD were more likely to perceive asthma as an acute, difficult to control illness and focused on the emotional aspects of medication use. There was no relationship between PTSD in caregivers and self-report of their children's asthma control, but children with poorly controlled asthma had caregivers with lower total AIRS scores.Caregivers' traumatic experiences impact their beliefs about their children's asthma. Future interventions targeting these beliefs could improve the manner in which they understand and treat their children's asthma.

As asthma presentation is episodic, patients with acute exacerbations often present in the emergency department (ED) where preventative regimen may not always be addressed. Addressing initiation and modification of controller medications in the setting of an acute exacerbation may facilitate improved asthma control and decrease the frequency of ED visits, particularly so for families who receive most of their asthma management in the ED. However, this aspect has not yet been explored.We reviewed a random sample of 363 charts, 10% of the total number of asthmatic children, aged 2-18, seen from January to December 2007 in the pediatric ED of an urban teaching hospital located in Bronx, NY, USA. We quantified the frequency of modification of the preventative regimen and the influence of seasons on this practice.Of these 363 children, 42.4% of patients were not previously on a controller medication. Of these, 9.7% were started on a new controller medication, with a significantly higher percent occurring in the summer months. Of those that were previously on a controller medication, 2.87% were started on a new controller medication and 0.95% had their controller medication dose increased. However, the regimen was not adjusted in 14.3% that had been seen four or more times in the preceding 2 years. Of the total 363 children, 78.5% were discharged from the ED on a short course of oral steroids, and this was not part of their preventative regimen. Only four charts had physician-documented asthma severity classification.We found that the preventative regimen was modified in only 0.9-2% of all asthmatic children seen in an urban ED whereas 78.5% were started on systemic steroids. Asthma severity was evaluated in a very small number of patients. Because modification of preventative regimen requires appropriate asthma severity classification, the inclusion of asthma severity classification as part of routine ED evaluation may encourage physicians to address controller medications in persistent asthmatics.

To explore the utility of two measures, Risk for Nonadherence (RN) and Admitted Nonadherence (AN), developed in a national sample of children with chronic asthma, for predicting short-term morbidity among children following a pediatric emergency department (PED) visit for acute asthma and to compare verbal and self-completion of these measures.Prospective cohort study of children 3 to 11 years of age presenting to a PED with an acute asthma exacerbation. Caretakers were randomized to self-completion of a questionnaire assessing RN and AN or to verbally respond to the same questionnaire administered by a research assistant. Five asthma morbidity indicators were collected at 2, 4, and 8 weeks following discharge from the PED.One hundred fifty-four patients were enrolled. There were no significant differences in asthma severity, RN, or AN, or the number of items missing on questionnaires between the self-completion and verbal administration groups. Patients with a RN score4 had an adjusted odds of 3.67 (95% confidence interval [CI] 1.57-8.58) for waking2 nights due to asthma symptoms. The adjusted odds of patients with any AN to report needing4 days of rescue asthma medication was 3.16 (95% CI 1.37-7.26).RN and AN were both associated with morbidity indices following an acute asthma exacerbation and can identify children at risk for increased short-term morbidity regardless of the method of questionnaire administration. Assessment of RN and AN by self-administered questionnaire during an ED visit for asthma maybe feasible.

To determine what percentage of inner-city children with asthma would lose asthma control when taken off asthma controllers, a retrospective analysis was performed on inner-city asthmatic children who achieved asthma control in an asthma specific disease management program. Once disease control was achieved patients had stepwise reduction of asthma controllers based on the National Asthma Education and Prevention Program (NAEPP) Expert Review Panel (EPR) 2 guidelines. In patients who were taken off all controllers, probability of maintaining asthma control at the first visit after cessation of these medications was significantly lower compared to patients kept on inhaled corticosteroids. We conclude that cessation of asthma controllers in previously well controlled inner-city asthmatic children results in loss of asthma control in a significant number of these patients. Data support recommendations from national asthma guidelines to step down controller therapy, but clinical monitoring is important to reduce impairment due to loss of control.

A cumulative risk framework was used to examine the impact of the presence of multiple risk factors on key asthma outcomes (i.e., health-related quality of life [HRQoL], severity) for a sample of 149 inner-city African-American youth with asthma. The presence of a greater number of risk factors was associated with lower HRQoL and greater severity, regardless of age or gender. Cumulative risk methodology, in combination with selection of risk factors based on theoretical and empirical work, is a viable option for researchers and clinicians who are interested in examining the impact of multiple risk factors on disease functioning and status.

This study examined patterns of agreement versus disagreement in family perceptions of caregiver and youth involvement in asthma management tasks and associations of these patterns with youth asthma outcomes. Fifty-six caregiver-child dyads completed questionnaires of family involvement in asthma management and asthma health outcomes (i.e., symptom days, health care utilization, and medication adherence). Discrepancies were documented for perceptions of both caregiver and youth involvement. Caregiver overestimation of youth involvement in asthma management was associated with greater asthma severity and more asthma symptoms. Discrepancies in family perceptions of involvement pose salient challenges for effective clinical management and require clinical attention.

Asthma education programs are reportedly effective for children and adolescents. Urban and minority children continue to have poor asthma outcomes and limited access to asthma education programs. The purpose of this study was to determine whether a library-based asthma education program, the Columbus Ohio Partnership for Inner-City Asthma Education (COPICAE), offered to urban and minority children (with their parents) could improve asthma-related outcomes and reduce billing claims for asthma-related hospital visits. A prospective/observational study was conducted to evaluate asthma-related outcomes of 87 children who completed 6 hours of asthma education using telephone follow-up at 12 and 24 months with a scored Living With Asthma Survey (LWAS). Hospital billing claims for asthma as the primary diagnosis were compared over a 24-month period for 64 children who completed 6 hours of asthma education with an age and zip code match control. Two separate focus groups with Spanish-speaking and English-speaking parents who completed 6 hours of asthma education with their children obtained parental perspectives about the asthma education classes. LWAS follow-up data were obtained on 67% of the participants at year 1 and 43% at year 2. Compared to pre-intervention mean scores, there were decreases in scores to all LWAS items. Parents reported improvements in compliance with asthma medication use and overall control of their child's asthma. Parents also found the information from the asthma education classes to be "beneficial." Total asthma-related billing claims for children who completed 6 hours of asthma education decreased 63.2%, while those for age and zip code matched controls increased 0.7%. Inner-city and minority children (with their parents) who attended 6 hours of asthma education offered in a public library showed improvements in asthma-related outcomes over a 24-month period and decreased billing claims for asthma-related hospital visits. Parents found 6 hours of asthma education to be beneficial in gaining basic knowledge about asthma and improving their child's illness control and self-esteem in living with asthma.

Information on parental asthma management practices for young children is sparse. The objective of this article is to determine if specific caregiver asthma management practices for children were associated with children's asthma morbidity. Caregivers of 100 inner-city children diagnosed with persistent asthma and participating in an ongoing asthma intervention study were enrolled and interviewed to ascertain measures of asthma morbidity, medication use, health care use (acute and primary care), and asthma management practices. Overall, asthma morbidity was high with almost two thirds of caregivers reporting their child having one or more emergency department visits within the last 6 months and 63% receiving specialty care for their asthma. Appropriate medication use was reported predominantly as albuterol and inhaled steroids (78%). However, only 42% of caregivers reported administering asthma medicines when their child starts to cough and less than half (39%) reported having an asthma action plan. There were no significant differences by asthma severity level for any asthma management practice. In conclusion, caregivers lack knowledge regarding cough as an early asthma symptom. Caregivers should be encouraged to review asthma action plans with health care providers at each medical encounter.

Percent predicted peak expiratory flow (PEF) is used to determine the severity of asthma exacerbation and the appropriateness of discharge from the emergency department (ED). The 1995 Global Initiative for Asthma and 1997 National Asthma Education and Prevention Program guidelines recommend using a patient's "personal best" PEF, if available, as a better measurement than the predicted PEF obtained from population-based nomograms. We evaluated the accuracy of personal best PEF as provided by inner-city ED patients with acute asthma. One hundred four patients with acute asthma agreed to return to the ED for repeat PEF measurements on days 3, 7, 12, 21, and 24 after their initial ED visits for acute asthma. At the ED visit, only 29% (30/104) of patients were able to report a personal best PEF. Over the 24 days of follow-up, 45% (10/22) of these patients had a measured PEF greater than their reported personal best. If a predicted PEF of at least 70% was used as the criterion for ED discharge, as several asthma guidelines recommend, then using patients' reported personal best PEF would have led to inappropriate ED discharge for some patients.

The purpose of this study was to identify the asthmatics living in the Lower West Side (LWS) of Buffalo, New York, and then explore the relationship between urban asthmatic and nonasthmatic exposures to many common household aeroallergens. Eight hundred twenty-eight households were visited and 167 asthmatics and 161 nonasthmatics were identified for comparison. Specific self-reported household exposure prevalences were identified for environmental tobacco smoke, sources of molds, household pets, rats, cockroaches, and sources of dust. Sources of molds, pets, and cockroaches were more likely to be found in the homes of asthmatics compared to nonasthmatics (p < 0.05). Other aeroallergens studied, although highly prevalent, were not more likely to be found in either asthmatic or nonasthmatic homes.

The purpose of this study was to improve asthma care and outcome in an inner-city emergency department. Consecutive adult patients (19,802) presenting with the diagnosis of acute asthma exacerbation to an inner-city municipal hospital emergency department, between July 1991 and December 1993, were prospectively evaluated. These patients were compared to a historical control group of 7923 consecutive asthma emergency department patients presenting in the year prior to our intervention. An asthma treatment guideline was implemented through a continuous quality improvement process. Asthma relapse rate and admission rate were obtained before and after the guidelines were instituted. Data after interventions were also prospectively compared to asthma outcomes at all other New York City municipal hospital emergency departments. After intervention, mean monthly asthma relapse rates showed a significant reduction from 12.18% to 7.83% (p < 0.001). A similar decrease was also noted in the monthly asthma admission rate, from 4.85 to 3.90 per 100 emergency department visits (p < 0.05). Asthma treatment guidelines along with continuous quality improvement techniques can significantly improve the outcome of inner-city emergency department asthma patients.

Lay definitions of asthma were elicited through a single open-ended question from a population-based sample of mostly Puerto Rican, inner-city residents in Buffalo, New York. One hundred fifty-five household responses to the question, "What do you think asthma is?" were analyzed qualitatively using the editing approach. Five common codes emerged in order of significance: "symptoms," "disease," "triggers," "threat," and "coping." Overall, expressions of illness reflected a largely symptomatic perception of asthma regardless of asthma status. Perceptions of "disease" increased with higher level of education. Patients' definitions of illness should be considered to help reduce interpersonal barriers to asthma care.

Asthma is the most common chronic disease of childhood and a leading cause of morbidity in adults. Despite significant advances in medical therapy, asthma morbidity and mortality rates have risen dramatically over the past two decades, especially in minority and socioeconomically disadvantaged populations. Numerous intervention programs have been designed in an attempt to reduce asthma morbidity but few have targeted poor or minority populations. The purpose of this study was to assess whether an outpatient intervention program specifically targeted at a high-minority population in East Harlem, in New York City, was successful in reducing asthma morbidity. A retrospective chart review of 84 patient records was conducted. The patients were divided into two groups, an intervention group (n = 45), who were followed by an asthma specialist (allergist/immunologist), and a nonintervention group, followed by a general internist or pediatrician. Outcome variables including clinic walk-in visits, emergency room visits, and hospitalizations were determined and compared in the pre- and postintervention period in both groups. Patients in the intervention group had reduced total walk-in visits (73 vs. 27, p < 0.001), emergency room visits (30 vs. 5, p < 0.001), and hospitalizations (16 vs. 2, p < 0.001). In contrast, patients in the nonintervention group had no change in total walk-in visits (88 vs. 72), increased emergency visits (7 vs. 22, p < 0.05), and no change in hospitalizations (5 vs. 2), respectively. The outpatient intervention program has been successful in reducing asthma morbidity in the high-risk minority community of East Harlem. Future larger studies are warranted to extend this pilot program to other high-risk minority populations.