Reduced asthma morbidity during COVID-19 in minority children: is medication adherence a reason?

OBJECTIVES: Asthma control improved during the COVID-19 pandemic. This study examined objectively measured medication adherence, asthma morbidity and quality of life (QoL) outcomes in Black and Latinx children by month for January-June 2019 (pre-COVID) compared to January-June 2020 (including first peak of COVID). METHODS: Secondary analyses of 94 children with asthma (ages 10-17 years, 64% Latinx, 36% Black) and their caregivers assigned to the comparison group of a longitudinal RCT intervention trial. Outcomes included mean aggregate electronic adherence for controller medications, oral steroid bursts, acute healthcare utilization, caregiver asthma QoL, and the Asthma Control Test. Repeated measures analyses were conducted due to multiple observations. RESULTS: Adherence to controller medications declined 48% from 2019 to 2020 (LS Mean = 33.9% vs. 17.6%, p=.0004, f=.92) with levels reaching a low in May 2020. A reduction in steroid bursts was observed over the same timeframe, 1.29 vs. 0.61, p = 0.006, f=.63. Caregiver QoL increased from 2019 to 2020 on total score (5.18 vs. 5.85, p = 0.002, f=.72), activity limitations (5.04 vs. 5.95), and emotional functioning (5.26 vs. 5.80). Although not statistically significant, a clinically meaningful 62% reduction in acute healthcare visits (p = 0.15) was reported in 2020. Children reported better asthma control (OR = 1.47, 95% CI 1.24, 1.73, p < 0.0001) in 2020 versus 2019 driven by improvements from May to June 2020. CONCLUSIONS: Decreased asthma morbidity in minority children during COVID was coupled with decreased adherence to controller medications. This observed decrease in morbidity is not explained by improvements in adherence.

Integrative Review of Programs to Improve Outcomes for Children With Comorbid Asthma and Anxiety/Depressive Symptoms.

Asthma is one of the most common pediatric chronic physical conditions. Youth with comorbid asthma and anxiety/depressive symptoms tend to have less controlled asthma and an increased use of health services in schools. The purpose of this integrative review was to examine the literature on educational and behavioral/ cognitive behavioral skills interventions for children with asthma and anxiety/depressive symptoms. Five electronic databases and forward/backward citations were searched. Eleven peer reviewed articles were retained for review. Main findings of the limited evidence suggest that educational and behavioral/cognitive behavioral skills programs may increase asthma knowledge and asthma-related self-efficacy while reducing anxiety/depressive symptoms. One study showed a decrease in use of quick relief inhalers and another had increased adherence to asthma controller medication. The literature indicates that educational and cognitive behavioral skills programs can have a positive impact on children with asthma and symptoms of anxiety/depression. School-based skills programs had better retention than outpatient programs.

A multilevel perspective on goals, barriers, and facilitators of school-based asthma management.

BACKGROUND: School based asthma care is being increasingly used to combat uncontrolled pediatric asthma. OBJECTIVE: The purpose of these secondary analyses was to explore multi-level perspectives regarding school-based asthma medical management for inner city, school-aged children with poor asthma control. METHODS: Sixty-six participants from two large U.S. urban school districts and key stakeholders participated in 1:1 interviews and focus groups. Participants were selected from across the asthma care community (children/caregivers, school personnel, nurses, pharmacists, healthcare providers, and administrators/insurers). Qualitative and descriptive techniques were used to analyze data. RESULTS: Goals: Children/caregivers prioritized living a normal active life with few asthma worries. Other stakeholders prioritized reducing student's asthma related emergency room visits and lost learning time. Facilitators: Continuity of care, strong relationships between care community members, and incentivizers were commonly suggested facilitators. School-based asthma management was viewed as a strong facilitator, particularly in the presence of a full-time school nurse. Barriers: Four themes were identified. (1) Greater systems and policy support for asthma management is needed in general, and at school in particular. (2) Overburdened families and systems often operate in crisis-mode, and asthma management is often not a priority until crisis is reached. (3) Discordance and distrust between members of the asthma care community can hinder shared asthma management. (4) Better communication is needed at all levels to improve care. CONCLUSION: Moving away from a crisis-based approach to asthma management for high-risk children will require increased systemic support for proactive asthma care and optimized communication within the asthma care community.Supplemental data for this article is available online at https://dx.doi.org/10.1080/02770903.2021.2018704.

Considerations in pediatric intervention research: Lessons learned from two pediatric pilot studies.

BACKGROUND AND PURPOSE: Pediatric populations represent a vulnerable research group. Careful thought must be given to many factors when designing and implementing pediatric intervention research studies. This article discusses methodological and implementation lessons learned from two pediatric intervention pilot studies and highlights facilitators and barriers encountered. TYPE OF METHOD: Both studies used a pre/post with 6-week follow-up method and were adapted versions of an evidence-based program, Creating Opportunities for Personal Empowerment (COPE). ESSENTIAL FEATURES: COPE is a 7-session, cognitive behavioral skills building intervention. COPE for Asthma was implemented in schools with small groups for elementary-aged children with asthma and symptoms of anxiety. Mindstrong to Combat Bullying was implemented individually in the outpatient mental health setting for adolescents who had experienced bullying with concurrent symptoms of depression/anxiety. METHODOLOGICAL APPLICATION: Both intervention studies were successful in achieving their research aims, but more importantly the authors learned important lessons in how to successfully work with pediatric populations in research studies. Legal considerations, such as mandated reporting, suicide risk assessment and the inclusion of parents are reviewed. Other components, such as working with children vs. adolescents, integrating research into school-based settings vs. clinic-based settings, and completing intervention research in a group setting vs. individual setting are discussed. CONCLUSIONS: The two pilot studies highlight important factors to consider when designing and implementing pediatric intervention studies. While challenges arise in working with this vulnerable population, research is ultimately needed to provide the best evidence-based care for our future generations. CLINICAL TRIAL REGISTRATION: The COPE for Asthma study is registered at www. CLINICALTRIALS: govNCT03481673.

Sustained Effects From a School-Based Intervention Pilot Study for Children With Asthma and Anxiety.

Children with chronic conditions (i.e., asthma) are more likely to have anxiety or depressive symptoms. Comorbid asthma and anxiety in children leads to increased morbidity, causing children to miss instructional time and parent/caregiver (CG) work absences. Asthma educational programs and mental health interventions have been developed, though no scalable programs integrate asthma education and mental health behavioral interventions for school-aged children. This study evaluated the sustained preliminary effects of an integrated asthma education and cognitive behavioral skills-building program, Creating Opportunities for Personal Empowerment for Asthma. Thirty-two children ages 8-12 years with asthma and symptoms of anxiety received the intervention. At 6-weeks postintervention, anxiety and CG-reported behavioral symptoms were significantly reduced, there were fewer missed doses of asthma controller medications, and asthma-related self-efficacy, personal beliefs, and the children's understanding of asthma significantly increased. Most children (n = 29, 91%) reported continued use of coping skills.

Explanatory Model for Asthma Disparities in Latino Children: Results from the Latino Childhood Asthma Project.

BACKGROUND: Little research has been conducted that integrates, in one explanatory model, the multitude of factors potentially leading to disparities among Latino children. PURPOSE: A longitudinal, observational study tested an explanatory model for disparities in asthma control between Mexican and Puerto Rican children with persistent asthma requiring daily controller medication use. METHODS: Mexican and Puerto Rican children aged 5-12 years (n = 267) and their caregivers (n = 267) were enrolled and completed interviews and child spirometry at baseline and 3, 6, 9, and 12 months postenrollment. A 12 month retrospective children's medical record review was completed. Participants were recruited from two school-based health clinics and the Breathmobile in Phoenix, AZ, and two inner-city hospital asthma clinics in the Bronx, NY. RESULTS: Statistically significant differences in the social/contextual predictors of asthma illness representations (IRs) were noted between Mexican and Puerto Rican caregivers. The structural equation model results revealed differences in asthma control over time by ethnicity. This model accounted for 40%-48% of the variance in asthma control test scores over 12 months. Caregivers' IRs aligned with the professional model of asthma management were associated with better children's asthma control across 1 year. These results also supported the theoretical notion that IRs change over time impacting caregivers' treatment decisions and children's asthma control. CONCLUSIONS: These findings extend a previous cross-sectional model test using a more comprehensive model and longitudinal data and highlight the importance of considering within-group differences for diagnosis and treatment of children coming from the vastly heterogeneous Latino umbrella group. TRIAL REGISTRATION: Trial number NCT01099800.

A missed primary care appointment correlates with a subsequent emergency department visit among children with asthma.

OBJECTIVE: Since the Affordable Care Act's implementation, emergency department (ED) visits have increased. Poor asthma control increases the risk of acute exacerbations and preventable ED visits. The Centers for Medicare and Medicaid Services support the reduction of preventable ED visits to reduce healthcare spending. Implementation of interventions to avoid preventable ED visits has become a priority for many healthcare systems yet little data exist examining children's missed asthma management primary care (PC) appointments and subsequent ED visits. METHODS: Longitudinal, retrospective review at a children's hospital was conducted for children with diagnosed asthma (ICD-9 493.xx), ages 2-18 years, scheduled for a PC visit between January 1, 2010, and June 30, 2012 (N = 3895). Records were cross-referenced with all asthma-related ED visits from January 1, 2010 to December 31, 2012. Logistic regression with maximum likelihood estimation was conducted. RESULTS: None of the children who completed a PC appointment experienced an ED visit in the subsequent 6 months whereas 2.7% of those with missed PC appointments had an ED visit (χ2 = 64.28, p <.0001). Males were significantly more likely to have an ED visit following a missed PC appointment than females (χ2 = 34.37, p <.0001). There was a statistically significant interaction of sex × age. Younger children (<12 years) made more visits than older children. CONCLUSIONS: The importance of adherence to PC appointments for children with asthma as one mechanism for preventing ED visits was demonstrated. Interventions targeting missed visits could decrease asthma-related morbidity, preventable ED visits, and healthcare costs.

A systematic review of mediators of physical activity, nutrition, and screen time in adolescents: Implications for future research and clinical practice.

BACKGROUND: Adolescents are not meeting current recommendations for daily physical activity, nutrition, and screentime which has been associated with overweight and obesity. Understanding the mediators that facilitate teens in improving their healthy lifestyle behaviors may be helpful in halting this crisis. PURPOSE: The purpose of this systematic review was to assess published findings regarding mediators of adolescent energy balance behaviors. METHOD: We followed the Institute of Medicine guidelines for completing a systematic review. DISCUSSION: Fourteen analyses from 12 studies were included with mediating variables tested for nutrition, physical activity, and screen time. Mediators were identified for all three behaviors and were primarily on the individual level of the social ecological model. CONCLUSIONS: Combining findings from this and other reviews of mediators can help guide researchers in choosing mediating factors for specific target behaviors.

Summary of the 2020 focused updates to U.S. asthma management guidelines: What has changed and what hasn't?

ABSTRACT: Despite the availability of effective medications, the majority of pediatric and adult patients with persistent asthma have uncontrolled symptoms. This has been attributed to patient nonadherence and poor self-management, but clinicians also contribute through inaccurate assessment of asthma and lack of familiarity with best practice guidelines for medication management. Thus, improving patient outcomes will require improving clinical management by health care providers, including utilization of evidence-based practice guidelines. In this report, we briefly summarize key points of the national guidelines for asthma management and delineate important changes enacted by 2020 Expert Panel Report-4 updates. These include revised recommendations on the use of fractional exhaled nitric oxide testing, indoor allergen mitigation, bronchial thermoplasty, adjunctive immunotherapy, and important modifications to medication management that are likely to have widespread impact on prescribing throughout the United States. In particular, for all patients aged five years and older taking stepwise therapy levels 3-4, it is now recommended to use Single Maintenance and Reliever Therapy, whereas the use of intermittent inhaled corticosteroids (ICSs) administered at the same time as short-acting beta agonist is recommended for step 2 to reduce symptom burden, improve control, and minimize total ICS dose.

Interventions to Improve Mental Health, Well-Being, Physical Health, and Lifestyle Behaviors in Physicians and Nurses: A Systematic Review.

OBJECTIVE: This systematic review focused on randomized controlled trials (RCTs) with physicians and nurses that tested interventions designed to improve their mental health, well-being, physical health, and lifestyle behaviors. DATA SOURCE: A systematic search of electronic databases from 2008 to May 2018 included PubMed, CINAHL, PsycINFO, SPORTDiscus, and the Cochrane Library. STUDY INCLUSION AND EXCLUSION CRITERIA: Inclusion criteria included an RCT design, samples of physicians and/or nurses, and publication year 2008 or later with outcomes targeting mental health, well-being/resiliency, healthy lifestyle behaviors, and/or physical health. Exclusion criteria included studies with a focus on burnout without measures of mood, resiliency, mindfulness, or stress; primary focus on an area other than health promotion; and non-English papers. DATA EXTRACTION: Quantitative and qualitative data were extracted from each study by 2 independent researchers using a standardized template created in Covidence. DATA SYNTHESIS: Although meta-analytic pooling across all studies was desired, a wide array of outcome measures made quantitative pooling unsuitable. Therefore, effect sizes were calculated and a mini meta-analysis was completed. RESULTS: Twenty-nine studies (N = 2708 participants) met the inclusion criteria. Results indicated that mindfulness and cognitive-behavioral therapy-based interventions are effective in reducing stress, anxiety, and depression. Brief interventions that incorporate deep breathing and gratitude may be beneficial. Visual triggers, pedometers, and health coaching with texting increased physical activity. CONCLUSION: Healthcare systems must promote the health and well-being of physicians and nurses with evidence-based interventions to improve population health and enhance the quality and safety of the care that is delivered.

COPE for asthma: Outcomes of a cognitive behavioral intervention for children with asthma and anxiety.

Asthma is the most common childhood chronic condition and a major contributor to school absences and lost instructional time. Children with asthma have a higher risk of internalizing disorders, such as anxiety and depression, which can further complicate asthma management. The purpose of this pilot study was to assess the feasibility, acceptability, and preliminary effects of a manualized, cognitive-behavioral skills-building intervention for children with asthma and anxiety. The design for this study was a one-group, pre/posttest preexperimental with a 6-week follow-up. This article presents the immediate posttest follow-up results. Children between 8 and 12 years of age and their caregivers were recruited from three elementary schools in a large public school district in Ohio. Thirty-two children with asthma and symptoms of anxiety completed the Creating Opportunities for Personal Empowerment (COPE) for Asthma program. Caregivers completed surveys, but they did not participate in the intervention. Results indicated that the program was feasible to implement in small groups during the school day. Self-reported findings indicated a significant reduction in separation anxiety and increased personal beliefs, child-management self-efficacy, and asthma illness representations. Parents and caregivers reported symptom reduction in their children on the Pediatric Symptom Checklist. The subgroup of children scoring high on anxiety at baseline showed reductions with the intervention, having large positive effect sizes for separation and social anxiety as well as medium and large positive effect sizes on the personal beliefs and asthma illness representations, respectively. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Longitudinal Patterns of Mexican and Puerto Rican Children's Asthma Controller Medication Adherence and Acute Healthcare Use.

Rationale: Researchers tend to study Latinos as a single group, but recent asthma research confirmed differences among Latino subgroups. Variations in controller medication adherence may be a factor in the observed health disparities between Mexican and Puerto Rican children. Adherence is not a stable phenomenon; however, there is a paucity of data on patterns of adherence, sociodemographic predictors of patterns, and variations in asthma-related acute healthcare use by adherence pattern among Latino subgroups. Objectives: To identify patterns of inhaled corticosteroid medication adherence over 12 months among Mexican and Puerto Rican children with persistent asthma, to examine sociodemographic predictors of adherence patterns by ethnicity, and to investigate asthma-related acute healthcare use based on these patterns. Methods: We analyzed controller medication Doser data from Mexican and Puerto Rican children (n = 123; ages 5-12 yr) with persistent asthma who participated with their caregivers in a longitudinal nonintervention study (Phoenix, AZ, and Bronx, NY). Interview and medical record data were collected at enrollment and at 3, 6, 9, and 12 months after enrollment. Results: Forty-seven to fifty-three percent of children had poor adherence (<50%) over each of the follow-up periods (cross-sectional). Children with lowest adherence were Puerto Rican, from nonpoor families, or female. Longitudinal latent class analysis yielded four adherence classes: poor, moderate, decreasing adherence, and increasing adherence. Puerto Rican children had significantly higher odds of "decreasing" (odds ratio [OR], 2.86; 95% confidence interval [CI], 0.40 to 20.50) and "poor" (OR, 5.62; 95% CI, 1.44 to 21.90) adherence than Mexican children. Females had significantly greater odds of "decreasing" (OR, 4.80; 95% CI, 0.73 to 31.74) and "poor" (OR, 5.20; 95% CI, 1.77 to 15.30) adherence group membership than males. The "decreasing" adherence group was comprised of only poor children. Children in the "poor" adherence class had the highest mean number of acute visits and emergency department visits/hospitalizations across all assessment periods. Conclusions: This study demonstrated that unique ethnicity within Latino populations may be associated with different risk levels for suboptimal controller medication adherence, which may be a factor in the observed asthma health disparities between Mexican and Puerto Rican children. Increased understanding of and attention to children's controller medication adherence patterns will provide evidence needed to identify children at highest risk for acute healthcare use and offer more-intensive intervention using less-intensive approaches for those at low risk. Clinical trial registered with www.clinicaltrials.gov (NCT01099800).

Factors Associated With Healthy Lifestyle Behaviors Among Adolescents.

OBJECTIVE: Guided by cognitive theory, this study tested an explanatory model for adolescents' beliefs, feelings, and healthy lifestyle behaviors and sex differences in these relationships. METHODS: Structural equation modeling evaluated cross-sectional data from a healthy lifestyle program from 779 adolescents 14 through 17 years old. RESULTS: Theoretical relationships among thoughts, feelings, and behaviors were confirmed and sex differences identified. Thoughts had a direct effect on feelings and an indirect effect through feelings on healthy behaviors for both sexes. A direct effect from thoughts to behaviors existed for males only. DISCUSSION: Findings provide strong support for the thinking-feeling-behaving triangle for adolescents. To promote healthy lifestyle behaviors in adolescents, interventions should incorporate cognitive behavioral skills-building activities, strengthening healthy lifestyle beliefs, and enhancing positive health behaviors.

Nursing Across the Lifespan: Implications of Lifecourse Theory for Nursing Research.

Despite the lifecourse focus of nursing clinical care, nursing research largely remains cross-sectional or process-oriented within silos determined by patient characteristics such as age, acuity, or disease process. Incorporating interdisciplinary lifecourse theory into pediatric nursing research provides the opportunity to expand nursing theories and research beyond practice, age, and disease silos. One such theory is the Lifecourse Health Development (LCHD) framework. LCHD takes a more expansive view of health development from preconception through old age based on the premise that health is a consequence of transactions between genetic, biological, behavioral, social, and economic contexts that change as a child develops over time (Halfon & Hochstein, 2002). LCHD also explains how intergenerational influences and prevention during early life help predict health development and disease over the lifespan. The preventive and lifecourse focus of LCHD is well-aligned with the lifespan wellness foci of pediatric nurses. The purpose of this article is to introduce pediatric nurse researchers to LCHD and discuss proposed augmentations and implications related to expanding LCHD into pediatric nursing research.

Physical health, lifestyle beliefs and behaviors, and mental health of entering graduate health professional students: Evidence to support screening and early intervention.

BACKGROUND AND PURPOSE: Little is known about the physical health, lifestyle beliefs and behaviors, and mental health among first-year health professional graduate students. Therefore, the purpose of this study was to describe these attributes as well as to explore the relationships among them. METHODS: A descriptive correlational study was conducted on the baseline data from a wellness onboarding intervention study with 93 health sciences students from seven different colleges within a large public land grant university in the Midwest United States. FINDINGS: Nearly 40% of the sample was overweight/obese, and 19% of students had elevated total cholesterol levels. Only 44% met the recommended 30 min of exercise 5 days per week. Forty-one percent reported elevated depressive symptoms and 28% had elevated anxiety. Four students reported suicidal ideation. Inverse relationships existed among depression/anxiety and healthy lifestyle beliefs/behaviors. CONCLUSIONS: Students entering health professional schools are at high risk for depression, anxiety, and unhealthy behaviors, which could be averted through screening and early evidence-based interventions. IMPLICATIONS FOR PRACTICE: Assessing the physical health, lifestyle behaviors, and mental health of first-year health sciences professional students is important to identify health problems and modifiable at-risk behaviors so that early interventions can be implemented to improve outcomes.