Depression among caregivers of children with asthma and its impact on communication with health care providers.

BACKGROUND: Caregiver depression is common, can negatively influence one's ability to communicate with health care providers, and may hinder appropriate care for children with asthma. OBJECTIVE: 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. METHODS: We enrolled caregivers of children (2-12 yrs) with persistent asthma prior to their health care 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. RESULTS: 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. CONCLUSIONS: 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.

Prevalence of rotavirus on high-risk fomites in day-care facilities.

STUDY OBJECTIVE: The objective of this study was to determine the prevalence of rotavirus contamination on environmental surfaces in day-care environments, using the polymerase chain reaction technique. DESIGN: High-risk fomites were identified in two day-care centers and sampled biweekly during a 6-month study period. Water samples from water-play tables in each center were also collected during the study period. During an infectious disease outbreak, fomites were sampled from the rooms in which the outbreak occurred. Reverse transcriptase/polymerase chain reaction was carried out for viral detection of rotavirus from the fomites, and standard bacteriologic measures were used to detect bacteria in samples from water-play tables. RESULTS: A total of 96 fomite samples were tested for presence of rotavirus from the two centers, of which 18/96 (19%) tested positive for rotavirus. The timing of the positive samples differed between the two centers. In the center that housed infants, a peak of rotavirus-positive fomites coincided with two enteric outbreaks. Rotavirus contamination was found on the telephone receiver, drinking fountain, water-play table, and toilet handles in both centers. Bacteria in large quantities were also identified in water-play table samples. CONCLUSIONS: Moist surfaces including the telephone, water fountains, and water-play tables are common sources of rotavirus contamination within the day-care environment. Until a safe and affordable drug or vaccine against rotavirus is available for general use, avoidance of rotaviral infections is the most effective method for the prevention of rotavirus gastroenteritis.

Infant health care utilization predicted by pattern of prenatal care.

STUDY OBJECTIVE: The objective of this study was to examine the relationship between patterns of prenatal care and subsequent infant health care use in a sample of inner-city women and their infants. In testing this relationship we controlled for several sociodemographic, economic, and psychological factors. DESIGN: This case-control study examined medical records of 148 infants born to mothers previously enrolled in a 9-month study of prenatal care and use or nonuse of illicit drugs. Cases (N = 62) were defined as infants born to women who first registered for prenatal care after 28 weeks' gestation or completed fewer than four prenatal visits. Controls (N = 86) were all other infants matched by date of birth. Data on maternal health and sociodemographic factors were obtained from a maternal interview and medical record review. Maternal drug use was defined as the use of illicit drugs at any time during the pregnancy based on maternal interview and/or a positive maternal or neonatal urine toxicology screen obtained within 48 hours of delivery. RESULTS: Infants of case mothers had significantly lower birth weight and gestational age, increased number of protective service referrals, and lower completion rate of three or more health supervision visits by 9 months of age. Multiple logistic regression analysis revealed that adequate prenatal care was significantly associated with adequate use of infant health care independent of maternal drug use, educational level, marital status, and number of previous living children. CONCLUSIONS: Patterns of infant health care use can be predicted before birth based on the mother's pattern of prenatal care use.

Medications used by children with asthma living in the inner city.

OBJECTIVE: The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables. DESIGN: The design of the study was a cross-sectional questionnaire survey. SETTING: Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992. PARTICIPANTS: A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families. INTERVENTION: The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report. RESULTS: More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with >/=20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children >/=9 years old supervised their own medication. CONCLUSIONS: We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.

Alcohol for surgical scrubbing?

To test the effects of four surgical scrub products on colonizing hand flora, 60 healthy adult volunteers were assigned by block randomization (12 subjects per group) to use one of the following formulations: 70% ethyl alcohol with 0.5% chlorhexidine gluconate (ALC); a liquid detergent base containing 1% triclosan (TRI); a liquid detergent base containing 4% chlorhexidine gluconate (CHG); a liquid detergent base containing 7.5% povidone-iodine (PI); or a nonantimicrobial liquid soap (control). Using standard protocol, subjects performed a surgical scrub daily for five consecutive days. Hand cultures were obtained at baseline and on test days 1 and 5 immediately after the scrub and following four hours of gloving. After the first and last scrubs, ALC, CHG and PI resulted in significant reductions in colonizing flora when compared to the control. Additionally, by day 5 ALC was associated with an almost 3-log reduction as compared to an approximate 1.5-log reduction for CHG and PI and less than a 1-log reduction of TRI and the control (p = .009). After four hours of gloving on both days 1 and 5, microbial counts on hands of subjects using ALC, TRI and CHG were significantly lower than counts for the control (p less than .001), whereas there was no significant difference in counts between the PI and control groups (p = .41). Skin assessment by study subjects rated products from least to most harsh as follows: control, TRI, CHG, ALC and PI p = .00001). It was concluded that ALC could be an efficacious and acceptable alternative for surgical scrubbing.

Postdoctoral nursing education in infection control: program description.

The need to identify and evaluate those clinical practices that are efficacious in reducing risk of nosocomial infection is clear. A model of large-scale programmatic evaluation is the Study of the Efficacy of Nosocomial Infection Control. Other important clinical studies have demonstrated the effectiveness of practices such as closed urinary drainage and management of intravascular lines and the ineffectiveness of such practices as double bagging and routine gowning in the newborn nursery. Clearly, research is one essential way to direct practice in infection control. It is our goal that the Johnson & Johnson/SURGIKOS Postdoctoral Nursing Fellows in Infection Control will make a significant contribution to the knowledge base in the specialty. The need for collaboration by government, industry, and academia in addressing health care research needs has been recently emphasized. We also believe that this Program can serve as one model for such a collaborative effort.

Opinions, knowledge, and self-reported practices related to infection control among nursing personnel in long-term care settings.

BACKGROUND: Because educational needs of staff in long-term care facilities regarding infection control have, not been well studied, we conducted this study to measure long-term care staff members' knowledge, self-reported practices, and opinions about infection control and handwashing. METHODS: A pilot study was conducted with 24 staff members of one long-term care facility to examine psychometric properties of study instruments. All nursing staff members (n = 105) from two additional long-term care facilities then completed a 14-item knowledge questionnaire, 22-item opinion survey, and 26-item survey of self-reported handwashing practices. RESULTS: Respondents were predominantly female with mean age of 46 years; most had completed high school. Mean length of employment in the study facility was 12.4 years. Registered nurses and licensed practical nurses scored significantly higher on knowledge (p = 0.0002) but significantly lower on self-reported practices (p = 0.01) than did trained nursing assistants. There was no significant correlation between self-reported practices and opinions regarding handwashing (p = 0.55). Neither level of knowledge nor positive opinion about the value of handwashing was associated with self-reported increases in handwashing practices. CONCLUSION: We conclude that education alone is not likely to be associated with changes in handwashing behavior. Instruments developed and tested in this study can be used in further research to correlate self-reported with observed behavior and to evaluate the effects of interventions on knowledge, opinions, and self-reported handwashing behavior.

Occurrence of infectious symptoms in children in day care homes.

Transmission of enteric pathogens is facilitated in child day care centers, including family day care homes, by frequent and intimate exposure among susceptible hosts, with diaper changing as the highest-risk procedure for such transmission. The objective of this study was to evaluate the effectiveness of an intervention program in decreasing the incidence of infectious disease symptoms in children attending family day care homes during a 12-month period. Each of 24 family day care homes was randomly assigned to an intervention or control group. The intervention included four components: (1) a handwashing educational program and (2) use of vinyl gloves, (3) use of disposable diaper changing pads, and (4) use of an alcohol-based hand rinse by the day care provider. Symptoms of enteric disease (diarrhea and vomiting) were significantly reduced in intervention family day care homes (p less than or equal to 0.05), whereas respiratory symptoms were not significantly different between intervention and control family day care homes (p = 0.35). Diarrhea was reported in 1 of every 100 child care days, representing one diarrhea episode per month in a typical family day care home.

Alcohol-impregnated wipes as an alternative in hand hygiene.

The antimicrobial effectiveness of four hand-wash products for health care personnel included three liquid soaps that contained 4% chlorhexidine gluconate, 1% triclosan, or no antiseptic ingredient, respectively, and a 30% w/w ethyl alcohol-impregnated hand wipe. These products were evaluated for reduction in bacterial counts on hands after extended use of 15 handwashes per day for 5 consecutive days. The order of greatest to least log reduction among products at the end of the 5-day test period was chlorhexidine gluconate (2.01), triclosan (1.52), alcohol wipe (0.04), and control soap (0.03). Skin condition before and after handwash was assessed for each treatment group. Subjects reported less skin irritation with alcohol wipes than with the two antiseptic products. Repeated washing with alcohol wipes results in reductions in bacterial colony counts comparable with nonmedicated soap, sufficient to prevent transmission of pathogens by the hands in most situations that arise in nonacute health care settings. This evidence, in addition to increased user acceptability reported by the subjects who used alcohol wipes, suggests that alcohol wipes are an acceptable alternative to soap-and-water handwashing in nonacute health care settings.

Nebulizer use in inner-city children with asthma: morbidity, medication use, and asthma management practices.

OBJECTIVE: To assess the frequency of nebulizer use, describe morbidity and patterns of medication administration, and examine the potential relationships between inhaled anti-inflammatory medication administration, asthma morbidity, and asthma management practices in children with asthma using a nebulizer compared with children with asthma not using a nebulizer. RESEARCH DESIGN: A cross-sectional, descriptive survey of previous events. SETTING: Elementary schools and participants' homes in Baltimore, Md, and Washington, DC. PARTICIPANTS: Six hundred eighty-six families of children aged 5 to 12 years with a diagnosis of at least mild, persistent asthma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Asthma morbidity, health care utilization, pattern of asthma medication administration, nebulizer use, and asthma management data were collected by telephone survey administered to caregivers. Nebulizer use was defined as use at least 1 or more days per month during the last 6 months. Of 686 children identified, 231 (33%) reported current nebulizer use. Nebulizer users had significantly increased lifetime hospital admissions, hospitalizations, and emergency department visits in the last 6 months compared with nonnebulizer users. Inhaled corticosteroid administration was low for both groups (nonnebulizer users, 8%; nebulizer users, 15%). In the nebulizer users group, administration of inhaled anti-inflammatory medications was associated with increased asthma morbidity (increased hospitalizations, days and nights with symptoms, and oral steroid use). CONCLUSIONS: Nebulizer use by inner-city children with asthma is higher than anticipated but is not associated with reduced asthma morbidity. This group of high-risk children was undertreated with inhaled corticosteroids for long-term control of asthma despite reports of adequate monitoring by a primary care physician.

Effectiveness of a home intervention for perceived child behavioral problems and parenting stress in children with in utero drug exposure.

OBJECTIVE: To determine if a home-based nurse intervention (INT), focusing on parenting education/skills and caregiver emotional support, reduces child behavioral problems and parenting stress in caregivers of in utero drug-exposed children. DESIGN: Randomized clinical trial of a home-based INT. SETTINGS: Two urban hospital newborn nurseries; homes of infants (the term infant is used interchangeably in this study with the term child to denote those from birth to the age of 36 months); and a research clinic in Baltimore, Md. PARTICIPANTS: In utero drug-exposed children and their caregivers (N = 100) were examined when the child was between the ages of 2 and 3 years. Two groups were studied: standard care (SC) (n = 51) and INT (n = 49). INTERVENTION: A home nurse INT consisting of 16 home visits from birth to the age of 18 months to provide caregivers with emotional support and parenting education and to provide health monitoring for the infant. MAIN OUTCOME MEASURES: Scores on the Child Behavior Checklist and the Parenting Stress Index. RESULTS: Significantly more drug-exposed children in the SC group earned t scores indicative of significant emotional or behavioral problems than did children in the INT group on the Child Behavior Checklist Total (16 [31%] vs 7 [14%]; P =.04), Externalizing (19 [37%] vs 8 [16%]; P =.02), and Internalizing (14 [27%] vs. 6 [12%]; P =.05) scales and on the anxiety-depression subscale (16 [31%] vs. 5 [10%]; P =.009). There was a trend (P =.06) in more caregivers of children in the SC group reporting higher parenting distress than caregivers of children in the INT group. CONCLUSIONS: In utero drug-exposed children receiving a home-based nurse INT had significantly fewer behavioral problems than did in utero drug-exposed children receiving SC (P =.04). Furthermore, those caregivers receiving the home-based INT reported a trend toward lower total parenting distress compared with caregivers of children who received SC with no home visits.

Maternal depressive symptoms and emergency department use among inner-city children with asthma.

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.

Prenatal care and drug use in pregnant women.

This case-control study tested the hypothesis that pregnant inner-city women with low utilization of prenatal care are likely to be frequent drug users. Cases registered consecutively for prenatal care at > or = 28 weeks gestation or had < 4 prenatal visits. Controls were matched to cases by date of delivery. 24/81 (30%) cases and 16/128 (12%) controls were frequent drug users (adjusted odds ratio = 2.5; 95% CI, 1.2-5.4). Drug use (P = 0.01) and socioeconomic status (P = 0.001) were significantly correlated with prenatal care utilization. Self-report alone failed to note as many drug users as toxicology screen alone. Both substance use history and toxicology screen are advisable in women with low utilization of prenatal care.

Factors associated with medication self-administration in children with asthma.

This study investigated factors associated with early self-administration of inhaled asthma medications by minority children. Specifically, the study evaluated: (1) the reasons parents allow early administration of inhaled medications, (2) childhood activities associated with early medication administration, (3) parent's perception of the child's ability to use a metered-dose inhaler (MDI), (4) the child's actual ability to use an MDI, and (5) concordance/discordance between physician-parent reports and parent-child reports of asthma medications. Study results indicated that 93% of the children were taking inhaled asthma medications without adult supervision. Early self-administration of asthma medications was related to the parent's employment status and the performance of other childhood behaviors such as completion of homework independently and crossing the street alone. Only 7% of the children had effective MDI skills, but 60% of the parents rated their child's MDI skills as excellent. Twenty percent, 67%, and 50%, respectively, of the parents' reports of beta-agonists, daily inhaled steroids, and cromolyn were discordant with the physician's actual prescriptions. Sixty-two percent, 57%, and 79%, respectively, of the children's reports for inhaled beta-agonists, daily inhaled steroids, and cromolyn were discordant with their parents' reports. Implications for anticipatory guidance, future educational strategies, and supervision of MDI technique are provided.

Social factors associated with behavioral problems in children with asthma.

The objective of this study was to describe the proportion of children with a behavior problem and examine which independent variables are associated with the presence of a behavior problem in a group of 392 inner-city children with asthma. Data on child asthma symptoms, medication use, health-care utilization, and school absences were obtained from the parent during a structured telephone interview. Included in the interview was a measure of behavior problems and social support questions. Children classified with a high level of asthma symptoms were more than twice as likely to experience a behavior problem than children classified with a low level of asthma symptoms (P = 0.002). Use of theophylline medication was not correlated with behavior problems (P = 0.45). Significant variables were low level of social support and high or moderate level of asthma symptoms. We have identified a group of children at risk for behavior problems, specifically in families that lack adequate social and financial resources.

Use of community health workers with inner-city children who have asthma.

Use of community health workers (CHWs) to obtain health, social, and environmental information from African-American inner-city children with asthma was one component of a larger intervention study designed to reduce morbidity in African-American children with asthma. A subset of 140 school-aged children with asthma was recruited and enrolled in a program to receive home visits by CHWs for the purposes of obtaining medical information and teaching basic asthma education to the families. Data obtained by the CHWs revealed low inhaled steroid use, high beta 2 agonist use, frequent emergency-room visits, decreased primary-care visits, and increased allergen and irritant exposure. Appropriately recruited and trained CHWs are effective in obtaining useful medical information from inner-city families with children with asthma and providing basic asthma education in the home.

Ethical conflicts experienced by certified pediatric nurse practitioners in ambulatory settings.

INTRODUCTION: The purpose of this descriptive study was to (a) identify the types of ethical conflicts and their resolutions reported by a group of certified pediatric nurse practitioners (CPNPs) in their ambulatory practice and (b) to examine demographic, educational, and practice-setting factors associated with these conflicts. METHOD: Five hundred fifty-nine CPNPs, identified by the National Association of Pediatric Nurse Associates and Practitioners, received survey questionnaires in the mail and were asked to participate by describing an ethical conflict in their practice. Questionnaires were completed by 118 CPNPs. Each ethical conflict was analyzed according to a four content analysis classification system to capture multiple relevant meanings. The relationship between types of ethical conflicts and demographic, educational, and practice-setting variables was examined. RESULTS: One third (34%) of the perceived ethical conflicts fell in the child/parent/practitioner relationship category. Most conflicts (31%) were experienced as a moral dilemma where 2 or more clear moral principles apply but they support mutually inconsistent courses of action. Most ethical conflicts (22%) were unresolved. DISCUSSION: Understanding the nature of ethical conflicts that CPNPs are experiencing in ambulatory settings is important. Professional and institutions/agencies need to collaborate on how to initiate appropriate ethics education and consultation for professional staff to recognize, discuss, and resolve ethical conflicts in the workplace.

Primary care for children with human immunodeficiency virus infection.

Pediatric human immunodeficiency virus (HIV) infection is now the seventh leading cause of death in U.S. children 1 to 14 years of age and the leading cause of death in children 2 to 5 years of age in many U.S. cities. The key to enhancing the quality and duration of life in HIV-infected children is to recognize and diagnose HIV infection as early as possible and to initiate prophylactic and antiretroviral therapies. Most of the medical treatment of these children can be conducted in a primary care setting if (a) primary care practitioners are informed of current treatment regimens and (b) adequate pediatric HIV consultation service is available. This article reviews the primary care of HIV-infected children including early diagnosis, current treatment options, and the complex psychosocial issues associated with caring for these children.

Care of HIV-risk infants: nursing outreach by PNPs.

In this prospective study, HIV-risk infants (infants born to women with a history of intravenous drug use, prostitution, or who is a sexual partner of an intravenous drug user) were followed during home visits by a pediatric nurse practitioner. Analysis of home visit records indicated that significant medical problems were detected in one out of every 12 visits, requiring referral of the infant for immediate medical attention. The most frequent problems/maternal concerns encountered during the home visits were infectious disease symptoms and skin conditions. The type of problems/maternal concerns did not differ by infant HIV status. With an increase in incidence of HIV infection in children, outreach by specialized nurses including PNPs is necessary to provide the intensive medical services required by these children.

Disclosure of HIV diagnosis to children: when, where, why, and how.

Despite recent recommendations by the American Academy of Pediatrics that strongly encourage disclosure of human immunodeficiency virus (HIV) infection to school-age children, health care providers vary widely in their actual disclosure practices. Concrete guidelines for accomplishing disclosure are not currently available. Nondisclosure can result in a variety of problems, including anxiety, depression, phobias, and exclusion from peer support groups and medical camps. This article reviews the available literature on disclosure of HIV infection to children and describes the disclosure process used in a large, urban pediatric HIV clinic.