Validation and psychometric properties of the neonatal intensive care unit parental beliefs scale.

BACKGROUND: Parental perception of their infants and confidence/beliefs about their parenting are among the most salient factors influencing outcomes of preterm infants. OBJECTIVES: The purpose of this study was to assess the psychometric properties of scores on the Neonatal Intensive Care Unit Parental Beliefs Scale (NICU PBS) in a sample of mothers and fathers of preterm infants receiving intensive care. The NICU PBS is a rating instrument designed to assess parental beliefs about their premature infant and their role during hospitalization. METHODS: The sample consisted of 245 mothers and 143 fathers. As part of the Creating Opportunities for Parent Empowerment trial, participants completed the NICU PBS 4-8 days after NICU admission and again approximately 4 days before discharge. Validation data were obtained at various times throughout the study. Confirmatory factor analysis was used to evaluate the NICU PBS factor structure. RESULTS: A three-factor solution was accepted (Parental Role Confidence, Parent-Baby Interaction, and Knowledge of the NICU). Reliability of scores on the total scale and subscales was high; Cronbach's alpha ranged from .75 to .91. Test-retest correlations ranged from .84 to .92. Younger maternal age; birth of another child; return to work within the past 12 months; and lower stress, depression, and anxiety were all significantly associated with higher scores on all subscales and the total score. Lower education, lower household income, receipt of Medicaid, and non-White race were associated with higher scores on the parent role confidence subscale and total. Lower household income and receipt of Medicaid were associated with higher Parent-Baby Interaction scores. DISCUSSION: The NICU PBS can be used reliably with mothers and fathers of premature infants who are hospitalized in the NICU, and it may be a useful scale in predicting parental stress, depression, and anxiety.

Perception of pulmonary function and asthma control: the differential role of child versus caregiver anxiety and depression.

OBJECTIVE: To examine child and caregiver anxiety and depression as predictors of children's perception of pulmonary function, quick-relief medication use, and pulmonary function. METHOD: 97 children with asthma, ages 7 to 11 years old, reported their anxiety and depressive symptoms and completed spirometry. Caregivers completed a psychiatric interview. Children's predictions of their peak expiratory flow were compared with actual values across 6 weeks. Quick-relief medication use was assessed by Dosers. RESULTS: Children's anxiety symptoms were associated with over-perception of respiratory compromise and greater quick-relief medication use. Children's depressive symptoms were associated with greater quick-relief medication use, but not perception of pulmonary function. Children of caregivers with an anxiety or depressive disorder had lower pulmonary function than children of caregivers without anxiety or depression. CONCLUSIONS: Child anxiety was associated with a subjective pattern of over-perception. Caregiver anxiety and depression were risk factors for lower lung function assessed by objective measurement.

Prediction of peak flow values followed by feedback improves perception of lung function and adherence to inhaled corticosteroids in children with asthma.

BACKGROUND: Failure to detect respiratory compromise can lead to emergency healthcare use and fatal asthma attacks. The purpose of this study was to examine the effect of predicting peak expiratory flow (PEF) and receiving feedback on perception of pulmonary function and adherence to inhaled corticosteroids (ICS). METHODS: The sample consisted of 192 ethnic minority, inner-city children (100 Puerto Rican, 54 African-American, 38 Afro-Caribbean) with asthma and their primary caregivers recruited from outpatient clinics in Bronx, New York. Children's PEF predictions were entered into an electronic spirometer and compared with actual PEF across 6 weeks. Children in one study were blinded to PEF (n=88; no feedback) and children in a separate study were able to see PEF (n=104; feedback) after predictions were locked in. Dosers were attached to asthma medications to monitor use. RESULTS: Children in the feedback condition displayed greater accuracy (p<0.001), less under-perception (p<0.001) and greater over-perception (p<0.001) of respiratory compromise than children in the no feedback condition. This between-group difference was evident soon after baseline training and maintained across 6 weeks. The feedback condition displayed greater adherence to ICS (p<0.01) and greater quick-relief medication use (p<0.01) than the no feedback condition. CONCLUSIONS: Feedback on PEF predictions for ethnic minority, inner-city children may decrease under-perception of respiratory compromise and increase adherence to controller medications. Children and their families may shift their attention to asthma perception and management as a result of this intervention.

A multi-factorial model for examining racial and ethnic disparities in acute asthma visits by children.

BACKGROUND: Causes of children's asthma health disparities are complex. Parents' asthma illness representations may play a role. PURPOSE: The study aims to test a theoretically based, multi-factorial model for ethnic disparities in children's acute asthma visits through parental illness representations. METHODS: Structural equation modeling investigated the association of parental asthma illness representations, sociodemographic characteristics, health care provider factors, and social-environmental context with children's acute asthma visits among 309 White, Puerto Rican, and African American families was conducted. RESULTS: Forty-five percent of the variance in illness representations and 30% of the variance in acute visits were accounted for. Statistically significant differences in illness representations were observed by ethnic group. Approximately 30% of the variance in illness representations was explained for whites, 23% for African Americans, and 26% for Puerto Ricans. The model accounted for >30% of the variance in acute visits for African Americans and Puerto Ricans but only 19% for the whites. CONCLUSION: The model provides preliminary support that ethnic heterogeneity in asthma illness representations affects children's health outcomes.

The relationship between caregivers' post-traumatic stress disorder and their asthma health beliefs in an ethnic minority inner-city sample.

OBJECTIVE: 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. METHODS: 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). RESULTS: 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. CONCLUSION: 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.

Validation of the Asthma Illness Representation Scale (AIRS).

BACKGROUND: Research has suggested a link between parents' illness representations (IRs), use of complementary and alternative medicine, inhaled/oral corticosteroids and leukotriene antagonists, and children's health outcomes. The Asthma Illness Representation Scale (AIRS) provides a structured assessment of the key components of asthma IRs allowing the healthcare provider (HCP) to quickly identify areas of discordance with the professional model of asthma management. METHODS: These analyses extend the initial validation of the AIRS and compares data from the original study conducted among a primarily white and African American sample in Rochester, NY (N = 228) with data obtained from a predominantly inner-city, ethnic minority sample (Puerto Rican, African American, and Afro-Caribbean) from the Bronx, New York (N = 109). RESULTS: A larger proportion of the Rochester sample was white and non-poor and had graduated high school. Bronx parents were more likely to perceive their child's asthma to be moderate or severe than the Rochester parents. Bronx children were older and had longer duration of asthma and reported more acute health care visits (past year). Bronx parents reported total AIRS scores more closely aligned with the lay model than Rochester parents. The AIRS instrument demonstrated acceptable internal reliability among the Bronx sample (total score alpha = 0.82) and the AIRS subscale Cronbach's alpha coefficients were remarkably similar to those obtained from the original validation study (range = 0.54-0.83). Poor parents and those with less than a high school education had lower total AIRS scores than their counterparts. White parents had AIRS scores more closely aligned with the professional model compared to each of the ethnic subgroups. A perception of less severe asthma, fewer reports of asthma and somatization symptoms, and a positive HCP relationship were associated with IRs congruent with the professional model. IRs aligned with the professional model were associated with fewer acute asthma-related healthcare visits. CONCLUSIONS: The AIRS instrument exhibited good internal reliability, external validity, and differentiated parents based on ethnicity, poverty, and education. Assessment of asthma IRs during the healthcare visit will allow the HCP and parent to discuss and negotiate a shared asthma management plan for the child, which will hopefully lead to improved medication adherence and asthma health outcomes.

Validation of the Asthma Illness Representation Scale-Spanish (AIRS-S).

BACKGROUND: To expand knowledge surrounding parental illness representations (IRs) of their children's asthma, it is imperative that culturally appropriate survey instruments are developed and validated for use in clinical and research settings. The Asthma Illness Representation Scale (AIRS) provides a structured assessment of the key components of asthma IRs, allowing the health care provider (HCP) to quickly identify areas of discordance with the professional model of asthma management. The English AIRS was developed and validated among a geographically and ethnically diverse sample. The authors present the validation results of the AIRS-S (Spanish) from a sample of Mexican and Puerto Rican parents. METHODS: The AIRS was translated and back translated per approved methodologies. Factor analysis, internal reliability, external validity, and 2-week test-retest reliability (on a subsample) were carried out and results compared with the validated English version. Data were obtained from 80 Spanish-speaking Mexican and Puerto Rican parents of children with asthma. The sample was recruited from two school-based health centers and a free medical clinic in Phoenix, Arizona, and a hospital-based asthma clinic in Bronx, New York. RESULTS: The original Nature of Asthma Symptoms, Facts About Asthma, and Attitudes Towards Medication Use subscales emerged. Remaining factors were a mixture of items with no coherent or theoretical distinction between them. Interpretation of results is limited due to not meeting the minimum requirement of 5 observations/item. Cronbach's alpha coefficients for the total score (alpha = .77) and majority of subscales (alpha range = .53-.77) were acceptable and consistent with the English version. Parental reports of a positive relationship with the HCP significantly predicted AIRS scores congruent with the professional model; longer asthma duration was associated with beliefs aligned with the lay model; and AIRS scores congruent with the professional model were related to lower asthma severity. Stability in AIRS-S scores over 2 weeks was demonstrated. CONCLUSIONS: The AIRS-S is a culturally appropriate instrument that can be used by HCPs to ascertain Spanish-speaking parents' asthma illness beliefs and assess discordance with the professional model of asthma management. This information can be used by the HCP when discussing parent's asthma management strategies for their children during clinical encounters.

Differential effects of a nurse home-visiting intervention on physically aggressive behavior in children.

OBJECTIVE: The objective of this study is to examine the differential effects of nurse home visiting (NV) on physical aggression (PA) among children aged 2-12 years. METHODS: This study used secondary data analysis from a randomized trial of NV intervention. RESULTS: There were significant reductions in PA observed among NV girls at 2 years old and NV children of high-psychological-resource mothers at 6 and 12 years old. Mediation analyses suggest that reductions in PA yield increased verbal ability among girls. CONCLUSIONS: Differential effects of intervention on PA by gender and mother's psychological resources highlight the importance of subgroup analyses. Identification of groups most likely to benefit may lead to more successful interventions.

Maternal rules, compliance, and injuries to preschool children.

This study examined the relationships among maternal rules, child compliance, and the injury experience of preschool children. To do so, 278 mothers of 3-year-old children were interviewed, mothers and children were videotaped, and medical records were reviewed. Results indicated that mothers' observed rule enforcement and children's committed compliance were inversely related to injury experience. The authors concluded that it is not the number or self-reported insistence on rules that are associated with injuries. Rather, it is only the mother's follow-through even in situations in which there was no perceived risk of injury that has an impact. Rules must be enforced and compliance encouraged in a manner that supports the development of autonomously motivated behavior.

Pediatric nurse practitioners' assessment and management of childhood overweight/obesity: results from 1999 and 2005 cohort surveys.

INTRODUCTION: Recently, public and professional emphasis has been placed on addressing the increasing prevalence of childhood overweight. METHOD: This survey study was conducted with two cohorts of pediatric nurse practitioners (N = 413) to explore differences in self-reported practice skills over time. RESULTS: Significant improvements in assessment, screening, and laboratory evaluations were reported, although reduced adherence to recommended psychosocial assessments was noted. DISCUSSION: This study outlines self-reported barriers to effective childhood weight management. One support that participants requested was evidence-based guidelines. Motivational interviewing may be an additional strategy to enhance provider skills to assess and manage challenging patient behavior change (e.g., dietary and activity changes).

Changes in nurse practitioners' knowledge and behaviors following brief training on the healthy eating and activity together (HEAT) guidelines.

INTRODUCTION: Primary care providers, particularly pediatric nurse practitioners, are an integral force involved in tackling the obesity epidemic among youth. The majority of nurse practitioners, however, report low proficiency regarding their ability to adequately prevent and treat pediatric overweight. In response, the National Association of Pediatric Nurse Practitioners (NAPNAP) developed the evidence-based Healthy Eating and Activity Together (HEAT) Clinical Practice Guideline (CPG) to improve provider behavior and efficacy. METHOD: Thirty-five nurse practitioners attending the NAPNAP Annual Conference participated in an intensive 4-hour HEAT CPG training session. Pre-training and post-training data were collected on provider knowledge, practice behaviors, and barriers in relation to the prevention of overweight among youth. RESULTS: Post-training results revealed significant improvements in (a) practitioner knowledge (assessment of patient growth, family history, psychosocial functioning, nutrition, and physical activity); (b) practitioners' intent to improve behavior (i.e., increased intent to use behavior modification and counseling aimed at patient and family behavior change); and (c) practitioners' report of increased confidence in ability to address barriers. DISCUSSION: Study findings demonstrate preliminary support for the HEAT CPG as an effective tool aimed at helping providers to improve their ability to maintain patients' healthy weight. Future research is needed to verify the effects of HEAT CPG on long-term improvements in care.

Changes in maternal depressive symptoms across the postpartum year at well child care visits.

OBJECTIVE: To describe the incidence, continuation, and resolution of symptoms during the postpartum year in urban women experiencing high depressive symptom levels at one or more well child care visits. METHODS: As part of a prior study of postpartum depressive symptoms, demographic data and the Edinburgh Postnatal Depression Scale (EPDS) were systematically collected from pediatric records of a clinic that routinely screens mothers with the EPDS at each first-year well child care visit. To explore the course of depressive symptoms throughout the postpartum year in this pilot study, we included only data from the records that had at least one EPDS > or = 10 (N = 100), a score indicating a high likelihood for clinically significant depressive symptoms. RESULTS: Among 49 women who completed the EPDS at least once before 3 months and between 3 and 11 months postpartum, 33% had high symptom levels throughout the year, 41% improved after the first 3 months, and 26% developed high symptom levels after the first 3 months. CONCLUSIONS: Postpartum depressive symptoms persist in many women throughout the postpartum year. Routine screening throughout the year might better identify both a subgroup of women who develop new symptoms during the year, as well as the women whose symptoms persist.

The language of breathlessness: do families and health care providers speak the same language when describing asthma symptoms?

INTRODUCTION: Effective communication about symptoms is a critical prerequisite to appropriate treatment. Study aims were to: (a) document the symptoms that children with asthma and their parents associate with asthma, (b) identify differences between the "professional model "of asthma symptoms and the "lay model," (c) describe the family's proposed action in response to symptoms, and (d) investigate the congruence between parental assessment of "good control" and severity obtained using National Asthma Education and Prevention Program criteria. METHOD: Children with asthma and their parents (N = 228) were recruited from diverse clinical practice sites. Parents and children described symptoms they associated with an asthma exacerbation and their proposed action. Perceived asthma control was compared with a structured assessment of severity. RESULTS: One hundred and thirty-six unique symptoms were reported. While 78% of parents reported at least one standard asthma symptom, 48% also reported nonstandard asthma symptoms. Sixty-five percent of parents whose children's symptoms were consistent with severe asthma reported "good control." DISCUSSION: Improved communication about symptoms would improve asthma care. Proposed strategies include standardized screening questionnaires to assess symptoms, more frequent routine visits for children with persistent asthma, and wide dissemination of realistic goals for symptom control.

The relationship between environment, efficacy beliefs, and academic achievement of low-income African American children in special education.

African American students are overrepresented in special education. Ecological systems theory, social cognitive theory, and a literature review demonstrate that children's environments, particularly school, and self-efficacy impact the educational outcomes of African American children. Interventions have aimed to improve children's environmental resources and efficacy. The aim of this study was to assess the impact of environment, efficacy beliefs, and the Nurse-Family Partnership intervention on the educational achievements of African American children in special education. A secondary data analysis of 126 African American children in special education found that self-efficacy and the number of hours spent in special education were associated with their academic achievement.

Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial.

OBJECTIVE: To examine the effect of prenatal and infancy nurse home visitation on the life course development of 19-year-old youths whose mothers participated in the program. DESIGN: Randomized trial. SETTING: Semirural community in New York. PARTICIPANTS: Three hundred ten youths from the 400 families enrolled in the Elmira Nurse-Family Partnership program. Intervention Families received a mean of 9 home visits (range, 0-16) during pregnancy and 23 (range, 0-59) from birth through the child's second birthday. MAIN OUTCOME MEASURES: Youth self-reports of educational achievement, reproductive behaviors, welfare use, and criminal involvement. RESULTS: Relative to the comparison group, girls in the pregnancy and infancy nurse-visited group were less likely to have been arrested (10% vs 30%; relative risk [RR], 0.33; 95% confidence interval [CI], 0.13-0.82) and convicted (4% vs 20%; 0.20; 0.05-0.85) and had fewer lifetime arrests (mean: 0.10 vs 0.54; incidence RR [IRR], 0.18; 95% CI, 0.06-0.54) and convictions (0.04 vs 0.37; 0.11; 0.02-0.51). Nurse-visited girls born to unmarried and low-income mothers had fewer children (11% vs 30%; RR, 0.35; 95% CI, 0.12-1.02) and less Medicaid use (18% vs 45%; 0.40; 0.18-0.87) than their comparison group counterparts. CONCLUSIONS: Prenatal and infancy home visitation reduced the proportion of girls entering the criminal justice system. For girls born to high-risk mothers, there were additional positive program effects consistent with results from earlier phases of this trial. There were few program effects for boys.

The effects of gender on the coping outcomes of young children following an unanticipated critical care hospitalization.

PURPOSE: A prior evaluation of the predictors of child coping outcomes following an unanticipated critical hospitalization revealed gender differences, which were explored in this study to examine patterns of behavioral change over time. DESIGN AND METHODS: Data from 163 mother-child (2-7 years) dyads were extracted for this study. Measures of child coping obtained 3 and 6 months following hospitalization included the Behavioral Assessment System for Children and the Post-Hospitalization Behavior Questionnaire. RESULTS: Maladaptive behaviors in girls increased throughout the 6-month post-hospitalization period. Boys demonstrated a peak and then decline of those same behaviors. PRACTICE IMPLICATIONS: Given this information, gender-specific child coping information can be developed for parents, which may lead to improved child outcomes.

Don't ask, don't tell: parental nondisclosure of complementary and alternative medicine and over-the-counter medication use in children's asthma management.

INTRODUCTION: Parent-health care provider (HCP) communication is an important component of pediatric asthma management. Given the high prevalence of complementary and alternative medicine (CAM) and over-the-counter (OTC) medication use among this population, it is important to examine parental nondisclosure of these asthma management strategies. METHOD: One-time interview and 1-year retrospective medical record review with 228 parents of 5- to 12-year-old children with asthma enrolled from six pediatric primary care practices examining parental nondisclosure of CAM and OTC medication use, reasons for nondisclosure, medical record documentation of CAM usage, and association between parent-HCP relationship and nondisclosure. RESULTS: Seventy-one percent of parents reported using CAM and/or OTC medication for children's asthma management, and 54% of those parents did not disclose usage. Seventy-five percent "did not think" to discuss it. Better parent-HCP relationship led to decreased nondisclosure. DISCUSSION: HCPs can play an important role in creating an environment where parents feel comfortable sharing information about their children's asthma management strategies in order to arrive at a shared asthma management plan for the child, leading to improved asthma health outcomes.

Complementary and alternative medicine use in children with asthma: prevalence and sociodemographic profile of users.

Research on complementary and alternative medicine use in children with asthma is in its infancy. This study examined the prevalence, types of CAM used and sociodemographic differences in CAM use among children 5-12 years with asthma. 65% of parents reported using CAM. Usage was highest among black, poor, lesser educated parents and children with persistent symptoms. Types of CAM differed by poverty and a trend for differences by race and education emerged. Health care providers who educate themselves on CAM therapies parents use for asthma can then discuss the implications of using these therapies and potentially improve adherence to the prescribed medication regimen.

The impact of the parental illness representation on disease management in childhood asthma.

BACKGROUND: Despite significant advances in treatment modalities, morbidity due to childhood asthma has continued to increase, particularly for poor and minority children. OBJECTIVES: To describe the parental illness representation of asthma in juxtaposition to the professional model of asthma and to evaluate the impact of that illness representation on the adequacy of the child's medication regimen. METHODS: Parents (n = 228) of children with asthma were interviewed regarding illness beliefs using a semistructured interview. The impact of background characteristics, parental beliefs, the child's symptom interpretation, and the parent-healthcare provider (HCP) relationship on the adequacy of the child's medication regimen were evaluated. RESULTS: The parental and professional models of asthma differ markedly. Demographic risk factors (p = .005), low parental education (p < .0001), inaccurate symptom evaluation by the child (p = .02), and a poor parent-HCP relationship (p < .0001) had a negative effect on the parental illness representation. A parental illness representation concordant with the professional model of asthma (p = .05) and more formal asthma education (p = .02) had a direct positive effect on the medication regimen. Demographic risk factors (p = .006) and informal advice-seeking (p = .0003) had a negative impact on the regimen. The parental illness representation mediated the impact of demographic risk factors (p = .10), parental education (p =.07), and the parent-HCP relationship (p = .06) on the regimen. DISCUSSION: Parents and HCPs may come to the clinical encounter with markedly different illness representations. Establishing a partnership with parents by eliciting and acknowledging parental beliefs is an important component of improving disease management.

Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial.

OBJECTIVE: Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2. METHODS: We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women <29 weeks' gestation, with previous live births and at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed), were randomly assigned to receive nurse home visits or comparison services. Primary outcomes consisted of intervals between births of first and second children and number of children born per year; mothers' stability of relationships with partners and relationships with the biological father of the child; mothers' use of welfare, food stamps, and Medicaid; mothers' use of substances; mothers' arrests and incarcerations; and children's academic achievement, school conduct, and mental disorders. Secondary outcomes were the sequelae of subsequent pregnancies, women's employment, experience of domestic violence, and children's mortality. RESULTS: Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes. CONCLUSIONS: By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.