Violence Exposure, Child Asthma Morbidity, and Maternal Depressive Symptoms: A Longitudinal Analysis of Cumulative Risk.

Low-income mothers of children with uncontrolled asthma are an underserved population at risk for psychological distress. We examined the impact of violence exposure and child asthma morbidity on depressive symptoms in mothers of youths with uncontrolled asthma. Asthma symptoms and health care utilization, socio-demographics, and standardized measures of depressive symptoms and violence exposure were ascertained by self-report. Latent Growth Curve Modeling tested the associations of violence and asthma morbidity with depressive symptoms. Participating mothers (N=276) reported high baseline violence exposure (59.5%) and depressive symptoms (34.4%); nearly a quarter had clinically significant depressive symptoms at 12 months. Violence exposure was consistently associated with maternal depressive symptoms. Individual indicators of asthma morbidity were nonsignificant, but the cumulative effect of asthma morbidity was predictive of higher depressive symptoms. Findings suggest holistic risk assessment and interventions may be needed to ameliorate the chronic distress observed in mothers of youths with uncontrolled asthma.

Reflection on education and clinical care of asthma for lung longevity (RECALL).

OBJECTIVE: Pediatric and adult asthma account for increased healthcare utilization. Preventative measures such as ongoing adherence of preventative medications from childhood to adulthood are essential for positive outcomes. To identify potential challenges for optimal pediatric asthma care, we surveyed adult patients to reflect on their asthma management practices, and education and treatment barriers when they were a child. METHODS: A descriptive cross sectional survey of specific and open-ended questions in an urban academic medical center. Adult asthmatics (18-30 years old) who participated in a previous pediatric asthma study or received care from the adult emergency department (ED) were enrolled. RESULTS: Forty-one adult asthmatic patients (mean (S.D.) age 22.5 (3.5) years and 65.9% females) participated in the survey. Reported childhood asthma related experiences include never attended an asthma education session in almost two-thirds surveyed; their mother or grandmother as the primary person responsible for administering their medications (95.1%); inhaled short-acting beta-agonist (SABA) use information was not helpful (46.3%); wanted to learn more about allergic triggers (78%); and the need for additional asthma educational sessions (48.7%). CONCLUSION: All healthcare providers are encouraged to provide continuous asthma education to their pediatric patients and their family members or guardian.

Fostering Effective Asthma Self-Management Transfer in High-Risk Children: Gaps and Opportunities for Family Engagement.

INTRODUCTION: The process of self-management knowledge, behavior, and skill development in children with asthma from families with low income is understudied. METHOD: Fifteen mothers of children with uncontrolled asthma participated in semistructured interviews exploring the transfer of asthma self-management responsibilities from parent to child. Team members performed thematic analysis of written transcripts. RESULTS: All participants were all the biological mothers and were impoverished, with most (73%) reporting an annual family income of less than $30,000. Their children ranged from 5 to 15 years old, were African American (100%), and had uncontrolled asthma based on national guidelines. Themes showed that child asthma self-management is difficult to achieve, that the transfer of asthma responsibility from mother to child is variable, and that mothers overestimate their child's developmental capacities for independent asthma self-management and have poor understanding of what well-controlled asthma means. DISCUSSION: Ongoing assessment and tailored guidance from health care providers are critical to support the pivotal role of mothers in their child's self-management development process.

Partner Notification, Treatment, and Subsequent Condom Use After Pelvic Inflammatory Disease: Implications for Dyadic Intervention With Urban Youth.

Research suggests that youth in urban communities often remain in the same sexual relationships after a pelvic inflammatory disease (PID) diagnosis. Utilizing data from the Technology Enhanced Community Health Nursing (TECH-N) study, we explored partner notification, treatment, and condom use after PID diagnosis. Outreach interviews assessed adherence to self-care behaviors, followed by interviews 3 months after diagnosis. Descriptive statistics and multivariable logistic regressions evaluated baseline condom use versus 3 months after diagnosis as it relates to group and relationship status. Ninety-one percent reported partner notification, and of those notified, 90% reported partner treatment. Reports of condom use increased in both groups compared with baseline use. TECH-N participants were more likely to report condom use at last sex at 3 months compared with baseline. Given the open communication with partners about PID and partner-associated effects on condom use, exploring dyadic intervention to promote consistent, condom use after PID for youth in high STI (sexually transmitted infection) prevalence communities is required.

Mixed-methods content and sentiment analysis of adolescents' voice diaries describing daily experiences with asthma and self-management decision-making.

BACKGROUND: Accurate symptom assessment remains challenging in teen populations. Little is known of usual symptom/response patterns, and self-reported paper diaries have traditionally low compliance rates. Therefore, we used concurrent digital voice diaries to capture daily asthma experiences. OBJECTIVE: (a) To qualitatively explore usual symptom patterns and self-management responses and (b) to quantitatively explore relationships between symptom severity and sentiment scores (a marker of emotional response to events). METHODS: Fourteen minority and nonminority teenagers (age 13-17) with controlled (50%) and uncontrolled asthma used digital recorders to report about their asthma once daily over 14 days. Dairy entries were coded for symptom frequency, severity, type, and self-management responses, while sentiment analysis was used to evaluate the emotional valence of diary entries and to explore whether increased symptom levels correlated with greater negative sentiment. RESULTS: Symptom frequency and severity recorded in voice diaries were much higher than teens indicated at baseline and were discordant with clinical assessments of asthma control. Of 175 entries, teens had symptoms 69.1% of days (121/175) and severe symptoms on one-third of these. Atypical symptoms (coughing, throat clearing) were reported twice as often as traditional symptoms (wheezing, chest tightness) and often not recognized as asthma, but rather attributed to being "sick" (25.6% of symptom days). Teens frequently minimized symptoms, used rescue and controller medication inconsistently, and resorted to alternative strategies to manage symptoms. Sentiment was not significantly correlated with assessed control (ß = 0.14, P = 0.28), but for teens reporting severe symptoms, sentiment scores decreased by 0.31 relative to teens without symptoms (P = 0.006). CONCLUSIONS AND CLINICAL RELEVANCE: Teens may minimize symptoms and have greater symptom frequency and severity than is recognized by themselves or providers. Screening for specific symptoms including coughing, throat clearing, and respiratory illness may be needed to identify those experiencing burden from asthma.

Association between second hand smoke (SHS) exposure and caregiver stress in children with poorly controlled asthma.

Objective: Urban children with asthma experience high rates of second hand smoke (SHS) exposure. The objective was to examine whether SHS exposure is associated with symptom frequency in children with poorly controlled asthma. Methods: Children were enrolled in a RCT to test the efficacy of an environmental control behavioral intervention versus an attention control group and followed over 12 months. SHS exposure assessed using salivary cotinine measurement. Frequency of child asthma symptoms, healthcare utilization, household smoking and caregiver daily life stress were obtained via caregiver report. Time of enrollment was recorded to assess seasonal factors. Symptom days and nights were the primary outcomes. Multivariable models and odds ratios examined factors that best predicted increased frequency of daytime/nighttime symptoms. Results: Children (n = 222) with a mean age of 6.3 (SD 2.7) years, were primarily male (65%), African American (94%), Medicaid insured (94%), and had poorly controlled asthma (54%). The final multivariable model indicated symptoms in the fall (OR 2.78; 95% CI 1.16, 6.52) and increased caregiver daily life stress (OR 1.13, 95% CI 1.02, 1.25) were significantly associated with increased symptom days when controlling for cotinine level, intervention status, child age and home and car smoking restrictions. Conclusions: There was no impact of SHS exposure on increased symptom frequency. High caregiver daily life stress and symptoms in fall season may place children with asthma at risk for increased day/nighttime symptoms. Close monitoring of symptoms and medication use during the fall season and intervening on caregiver life stress may decrease asthma morbidity in children with poorly controlled asthma.

Improving Care of Inner-City Children with Poorly Controlled Asthma: What Mothers Want You to Know.

INTRODUCTION: Low-income caregiver perspectives on asthma management are understudied but may illuminate strategies to improve care delivery and child outcomes. METHOD: Purposive sampling methods were used to recruit 15 caregivers of children with frequent asthma emergency department visits. Interviews explored how poverty and stress affect asthma management. Grounded theory coding techniques were used to analyze the data. RESULTS: Participants were the biological mother (100%) and were poor (75% had mean annual income ≤ $30,000). Their children (mean age = 6.9 years) were African American (100%), enrolled in Medicaid (100%), and averaged 1.5 emergency department visits over the prior 3 months. Four themes emerged: (a) Deplorable Housing Conditions, (b) Allies and Adversaries in School-Based Asthma Management, (c) Satisfaction With Asthma Health Care Delivery, and (d) Prevalent Psychological Distress. DISCUSSION: Impoverished caregivers of children with frequent asthma emergency department visits describe stress that is multifaceted, overwhelming, and difficult to eradicate. Their experiences underscore the need for improved school-based asthma management and family-centered approaches to health care delivery.

An integrated operational definition and conceptual model of asthma self-management in teens.

OBJECTIVES: A previous definition of adolescent asthma self-management was derived from interviews with clinicians/researchers and published literature; however, it did not incorporate perspectives of teens or parents. Therefore, we conducted in-depth interviews with teens and parents and synthesized present findings with the prior analysis to develop a more encompassing definition and model. METHODS: Focal concepts were qualitatively extracted from 14-day self-management voice-diaries (n = 14) and 1-hour interviews (n = 42) with teens and parents (28 individuals) along with concepts found in the previous clinical/research oriented analysis. Conceptual structure and relationships were identified and key findings synthesized to develop a revised definition and model of adolescent asthma self-management. RESULTS: There were two primary self-management constructs: processes of self-management and tasks of self-management. Self-management was defined as the iterative process of assessing, deciding, and responding to specific situations in order to achieve personally important outcomes. Clinically relevant asthma self-management tasks included monitoring asthma, managing active issues through pharmacologic and non-pharmacologic strategies, preventing future issues, and communicating with others as needed. Self-management processes were reciprocally influenced by intrapersonal factors (both cognitive and physical), interpersonal factors (family, social and physical environments), and personally relevant asthma and non-asthma outcomes. CONCLUSION: This is the first definition of asthma self-management incorporating teen, parent, clinician, and researcher perspectives, which suggests that self-management processes and behaviors are influenced by individually variable personal and interpersonal factors, and are driven by personally important outcomes. Clinicians and researchers should investigate teens' symptom perceptions, medication beliefs, current approaches to symptom management, relevant outcomes, and personal priorities.

Very Poorly Controlled Asthma in Urban Minority Children: Lessons Learned.

BACKGROUND: Very poorly controlled (VPC) asthma in children is associated with ongoing acute exacerbations but factors associated with VPC are understudied. OBJECTIVE: To examine the risk factors associated with VPC asthma in urban minority children. METHODS: This descriptive study examined asthma control levels (well-controlled [WC], not well-controlled [NWC], and VPC) at baseline and 6 months in children participating in an ongoing randomized controlled trial of an emergency department/home environmental control intervention. Data collection occurred during the index emergency department visit and included allergen-specific IgE and salivary cotinine testing and caregiver interview of sociodemographic and child health characteristics. Follow-up data were collected at 6 months. Unadjusted analyses examined the association of sociodemographic and health characteristics by level of asthma control. Multivariate analysis tested significant factors associated with VPC asthma at 6 months. RESULTS: At baseline most children were categorized with VPC asthma (WC, 0%; NWC, 47%; VPC, 53%) and rates of VPC minimally improved at 6 months (WC, 13%; NWC, 41%; VPC, 46%). Risk for VPC asthma was twice as likely in children with allergic rhinitis (odds ratio [OR], 2.42), having 2 or more primary care provider asthma visits within the past 3 months (OR, 2.77), or caregiver worry about medication side effects (OR, 2.13) and 3 to 4 times more likely when asthma control was assessed during the fall or spring season (OR: fall, 3.32; spring, 4.14). CONCLUSIONS: Improving asthma control in low-income, high-risk children with VPC asthma requires treatment of comorbidities, attention to caregiver medication beliefs, and adept use of stepwise therapy.

Characterization of Stress in Low-Income, Inner-City Mothers of Children with Poorly Controlled Asthma.

The goal of this longitudinal analysis was to characterize factors associated with the experience of life stress in low-income, inner-city mothers of minority children with high-risk asthma.Participants (n = 276) reported on family demographics, child asthma control and healthcare utilization, social support, contemporary life difficulties (housing, finances, violence exposure) measured by the validated Crisis in Family Systems scale, and daily stress. Latent growth curve modeling examined predictors of life stress across 12 months as a function of home and community difficulties, asthma-specific factors, and social support. Mothers were primarily single (73%), unemployed (55%), and living in extreme poverty with most (73%) reporting an annual family income <$20,000 (73%). The children were young (mean age = 5.59, SD = 2.17), African-American (96%), and had poorly controlled asthma (94%) at study enrollment. Higher daily stress was associated with financial difficulties, safety concerns in the home and community, and housing problems. Access to social support was consistently related to reduced stress. The only asthma-specific factor associated with life stress was healthcare utilization, with more emergency services for asthma related to higher daily stress. Findings underscore the clinical significance of assessing diverse home and community stressors and social support in low-income, inner-city caregivers of children with poorly controlled asthma.

The Effect of Sexual Abuse and Prenatal Substance Use on Successful Breastfeeding.

Barriers to breastfeeding in women with substance use disorders (SUDs) often exist. Neonatal abstinence syndrome-related feeding difficulties, maternal SUD-related maladaptive behaviors, and psychological comorbidities can adversely affect breastfeeding. A neglected barrier that frequently occurs in women with SUDs is a history of sexual abuse. It is important that nurses and providers understand each maternal and/or infant factor that can affect the breastfeeding course to assist effectively with lactation support for these frequently misunderstood dyads.

Caregiver perception of asthma management of children in the context of poverty.

OBJECTIVE: Low-income caregivers of young children with high-risk asthma experience social stressors and illness-related demands that may impede effective home asthma management. Knowledge of the caregiving experience in the context of poverty is limited. METHODS: Convenience sampling methods were used to recruit low-income caregivers of children aged 7-12 years, who are frequently in the Emergency Room (ED) for uncontrolled asthma. Thirteen caregivers participated in focus groups that were designed to elicit reflections on asthma home and community management from the caregiver perspective. A grounded theory approach was used in the open coding of transcript data from three focus groups, as well as to revise and reorganize emerging themes and sub-themes. RESULTS: Participants (Mean age = 33.9 years) were predominantly the biological mother (92.3%), single (84.6%), and impoverished (69.2% reported annual household income ≤ $30,000). Their children (Mean age = 7.8 years) were African-American (100%), enrolled in Medicaid (92.3%), averaged 1.38 (SD = 0.7) ED visits over the prior 3 months, resided in homes with at least one smoker (61.5%), and nearly all (84.6%) experienced activity limitations due to asthma. Five themes emerged in the analysis: intensive caregiving role, complex and shared asthma management responsibility, parental beliefs and structural barriers to guideline-based care, lack of control over environmental triggers, and parent advocacy to improve child asthma care and outcomes. CONCLUSIONS: Caregivers managing a child with high-risk asthma in the context of poverty indicate the need for ongoing asthma education, increased sensitivity to the complexity of home asthma management, and family-centered interventions that enhance communication and collaboration between caregivers and providers.

Perceptions and experiences underlying self-management and reporting of symptoms in teens with asthma.

BACKGROUND: Teens often have inadequate asthma self-management and control. However, little is known of their perceptions of or rationales for self-management behaviors. OBJECTIVES: To explore how teens self-manage asthma, including experiences, perceptions, responses to and reporting of symptoms. METHODS: A case-based, qualitative-descriptive design was used. Data were collected from minority and non-minority teens with controlled and uncontrolled asthma and their respective parents (N = 28). There were four data-collection points, including: (1) a primary teen interview; (2) parent interview; (3) 2-week self-management voice-diary; and (4) follow-up teen interview, incorporating symptom-response card-sorting to map symptoms and associated self-management responses. Seventy data sources were included in the analysis. RESULTS: Teens thought of their asthma symptoms as normal or unusual relative to their personal baseline symptom pattern; Those with uncontrolled asthma normalized higher levels of asthma symptoms than their counterparts with controlled asthma. Second, teens' decisions to treat symptoms of asthma with rescue medication were based on perceived benefits, burdens and accessibility of treatment balanced against perceived normalcy of symptoms. Teens with uncontrolled asthma had substantially higher treatment thresholds and delayed responses to symptoms compared to controlled peers. Third, teens never reported perceived normal symptoms of asthma to parents or providers, who were thus only aware of unusual or visible/audible symptoms. CONCLUSIONS: Teen's perceptions of symptoms and understanding of what is normal is the basis for self-management decisions. Improving self-management will likely entail modifying perceptions of symptoms and benefits/burdens of treatment to achieve healthier self-management patterns.

Asthma Home Management in the Inner-City: What can the Children Teach us?

OBJECTIVE: Knowledge of asthma home management from the perspective of poor, minority children with asthma is limited. METHOD: Convenience sampling methods were used to recruit families of low-income children who are frequently in the emergency department for uncontrolled asthma. Thirteen youths participated in focus groups designed to elicit reflections on asthma home management. Data were analyzed using grounded theory coding techniques. RESULTS: Participants (Mean age = 9.2 years) were African American (100%), enrolled in Medicaid (92.3%), averaged 1.4 (standard deviation = 0.7) emergency department visits over the prior 3 months, and resided in homes with at least 1 smoker (61.5%). Two themes reflecting multifaceted challenges to the development proper of self-management emerged in the analysis. DISCUSSION: Findings reinforce the need to provide a multipronged approach to improve asthma control in this high-risk population including ongoing child and family education and self-management support, environmental control and housing resources, linkages to smoking cessation programs, and psychosocial support.

Care-Seeking Behavior After Notification Among Young Women With Recurrent Sexually Transmitted Infections After Pelvic Inflammatory Disease.

UNLABELLED: Objective To determine the level of nurse case management and outreach required to notify young women with sexually transmitted infection (STI) positive test results after pelvic inflammatory disease (PID) and percent seeking treatment. METHODS: Participants (N = 153) were enrolled in a clinical trial of young women diagnosed with PID and followed for 3 months for recurrent STIs. Vaginal swabs were obtained at 1 and 3 months. All participants were notified of positive STIs at 1 and 3 months and treatment arranged. Data were analyzed with logistic regression for comparison of treatment status by number of nurse contacts. Results Over the 3-month period, 59 participants (38.6%) tested positive for one or more STIs and all received notification. Only 50% (19/38) of participants with STI at 1 month and 43% (16/37) at 3 months received treatment. Conclusions Despite the high notification rate of positive test results for young adults with recurrent STIs, many failed to seek treatment.

WIC Participation and Breastfeeding at 3 Months Postpartum.

Objectives Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower breastfeeding initiation and duration. This study examines breastfeeding-related factors among WIC participants and nonparticipants that might explain these previous findings. Methods Respondents to the 2007 Infant Feeding Practices Study II who were income-eligible for WIC were categorized as follows: no WIC participation (No-WIC); prenatal participation and infant entry while ≥60 % breastfeeding (WIC BF-high); prenatal participation and infant entry while <60 % breastfeeding (WIC BF-low). Percent breastfeeding was the number of breast milk feeds divided by the total number of liquid feeds. Using propensity scores, we matched WIC BF-high respondents to No-WIC respondents on demographic and breastfeeding factors. We used logistic regression to estimate the impact of WIC participation on breastfeeding at 3 months postpartum in the matched sample. Within-WIC differences were explored. Results Of 743 income-eligible respondents, 293 never enrolled in WIC, 230 were categorized as WIC BF-high, and 220 as WIC BF-low. Compared to matched No-WIC respondents, WIC BF-high respondents had increased odds of breastfeeding at 3 months, though this difference was not statistically significant (OR 1.92; 95 % CI 0.95-3.67; p value 0.07). WIC BF-high respondents were more similar on breastfeeding-related characteristics to No-WIC respondents than to WIC BF-low respondents. Conclusions for Practice Accounting for prenatal breastfeeding intentions and attitudes, we find no negative association between WIC participation and breastfeeding at 3 months postpartum. This is in contrast to prior studies, and highlights the importance of understanding within-WIC differences.

New approaches to qualitative interviewing: Development of a card sort technique to understand subjective patterns of symptoms and responses.

BACKGROUND: Ability to elicit individuals' perceptions of complex behavioral processes can be challenging, as it hinges not only upon the skill of the researcher, but also upon assumptions of a shared language and individuals' ability to recall, analyze, and effectively communicate events. In a case-based qualitative-descriptive study about teens' experiences of asthma self-management, we found that variations in terminology and descriptions of events, symptoms, and responses made it difficult to understand teens' experiences of asthma. In particular, teens' conceptualization of their asthma symptoms and self-management responses differed from situation to situation, from other teens in the study, from the interviewer, and from prior reports in the literature. These differences across many levels made it difficult to identify patterns in individual processes of self-management, and among teens in general.. OBJECTIVES: To address these challenges, we developed a card sorting activity to facilitate in-depth exploration of teens' experiences of asthma. DESIGN: Case-based qualitative description. SETTING: Teen-parent dyads (N=28) were recruited from the community, Emergency Department, Pediatric Pulmonary Department, and prior study subjects of a major medical center. METHODS: Teens first identified and then sequenced their own unique sets of asthma symptoms and self-management responses. Teens then developed contextually grounded narratives using the card sort they had created as a visual aid. RESULTS: This technique not only allowed us to bridge teen-interviewer communication barriers and develop shared terminology, but also resulted in a visible sequence of asthma symptoms and self-management responses. CONCLUSIONS: The card sort technique facilitated researcher-teen discussion and enabled comparison of self-management patterns across teens in our study. This technique is potentially useful for other areas of research exploring behavioral processes with complex and individual-specific experiences, in particular those involving sequences of events and self-management responses. This paper delineates the development, utility, and potential applications of the symptom-response card sorting technique for research and clinical practice.