Giving adolescents with cystic fibrosis a voice: Predicting cystic fibrosis nutritional adherence from their decision-making involvement.

OBJECTIVE: Suboptimal nutritional adherence in adolescents with cystic fibrosis (awCF) has been associated with lower lung function. AwCF often have more independence in dietary decisions than younger children, yet little research has examined how adolescent decision-making relates to nutritional adherence. This study explored whether components of adolescent decision-making involvement facilitate enzyme and caloric adherence in awCF. METHODS: 37 families participated and completed study procedures. AwCF and caregivers completed electronic surveys, including the Decision-Making Involvement Scale (DMIS). The DMIS evaluated awCF behaviors during nutrition-related decision-making/discussions with caregivers using DMIS subscales: Child Seek (asking for help/advice from caregivers), Child Express (awCF stating opinions) and Joint/Options (awCF participating in joint decision-making or caregiver providing options). AwCF completed 2, 24-hr diet recalls via videoconferencing/phone to estimate adherence. Chart reviews collected medical information. DMIS subscales were regressed onto enzyme and caloric adherence. RESULTS: 43% of awCF met calorie recommendations; 48.6% took all enzymes as prescribed. Caloric adherence was positively correlated with adolescent- and parent-reported Child Seek (r = 0.53; r = 0.36) and adolescent-reported Joint/Options (r = 0.41). Per adolescent-report, the caloric adherence regression model was significant, with Child Seek contributing unique variance in caloric adherence (ß = .62, p = .03). Parent-reported adolescent-decision-making involvement significantly predicted caloric adherence, but none of the subscales contributed unique variance. No other regressions were significant. CONCLUSIONS: When awCF participated in nutrition-related discussions with a caregiver, especially with questions, caloric adherence was better. Future research should examine whether family factors influence these results. AwCF are encouraged to ask questions in nutrition discussions.

Perceptions of African American Youth and Adults Regarding Tobacco Use-Related Factors in Their Community: A Mixed-Methods Approach in Richmond, Virginia.

INTRODUCTION: The US Food and Drug Administration is poised to restrict the availability of menthol cigarettes and flavored cigars, products disproportionately used by Black/African American (B/AA) individuals. We examined B/AA youth and adult perceptions regarding factors contributing to tobacco use, as well as prevention/cessation resources. METHODS: In 2 mixed-methods studies in Richmond, Virginia, we conducted cross-sectional surveys among youth (n = 201) and adult (n = 212) individuals who were primarily B/AA and reported past 30-day cigar smoking or nontobacco use, followed by focus groups with a subset (youth: n = 30; adults: n = 24). Focus groups were analyzed using a thematic analysis framework, and descriptive survey data provided context to themes. RESULTS: Among focus group participants, 20% of youth and 75% of adults reported current cigar smoking. Six themes emerged across the groups: advertising/brands, sensory experiences, costs, social factors, youth-related factors, and dependence/cessation. Youth and adults perceived cigars as popular; cigar use was attributed to targeted advertising, flavors, affordability, and accessibility. While adults expressed concern regarding youth tobacco use, youth did not perceive tobacco prevention programs as helpful. Adults and youth reported limited access to community tobacco prevention/cessation programs. DISCUSSION: Expanded tobacco prevention and cessation resources for B/AA people who smoke could leverage federal regulatory actions to ban tobacco products targeted toward this group and decrease disparities in tobacco-related morbidity and mortality.

Perceived discrimination and mental health outcomes in college students: the mediating effect of preventive health behaviors and social support.

Objective: To examine the role of social support and health behaviors in the association between discrimination and mental health (e.g., anxiety/depressive symptoms, suicidal ideation) among college students experiencing various forms of discrimination. Participants: Data were collected from 709 college students (42.8% White; 72.2% female) at a large urban university in Fall 2017. Methods: Students completed an online survey assessing perceived discrimination, anxiety/depressive symptoms, suicidal behavior, health behaviors, and social support. Moderation and parallel mediation analyses were conducted in PROCESS SPSS. Results: Results indicated that preventive health behaviors and social support partially mediated associations between discrimination and mental health outcomes. Conclusions: Findings highlight the need to increase awareness regarding engaging in preventive health behaviors on college campuses. For students experiencing discrimination, prevention, and social support might be key factors in improving mental health.

Changes in caregiver mental health and pediatric asthma control during COVID-19.

OBJECTIVE: This study evaluated caregivers' stress and depressive symptoms, and children's asthma control, before COVID-19 began and after its onset among families in the RVA Breathes program. METHODS: The RVA Breathes intervention, which took place in an urban city in the United States, includes asthma education delivered by a community health worker (CHW), a home assessment, and school nurse components. Participants included 125 children (5-11 years) with asthma and their caregivers (48% household income <$25,000) enrolled prior to the pandemic. Families were randomized to an active intervention arm (full intervention or intervention without school nurse component) or the control group. Caregivers completed the Center for Epidemiological Studies Depression Scale (CES-D) and the Perceived Stress Scale (PSS); children and caregivers completed the Childhood Asthma Control Test (cACT). Assessments pre-COVID-19 were compared to those completed after the pandemic's onset. RESULTS: Children in both intervention groups had better cACT scores after the start of COVID-19 compared to before (t(55) = -2.131, p = .019; t(28) = -2.893, p = .004). Caregivers in the intervention groups had lower PSS scores after the start of COVID-19 compared to pre-COVID-19 (t(53) = 3.928, p < .001; t(28) = 2.568, p = .008). Furthermore, CES-D scores improved among caregivers in the full intervention (t(48) = 1.789, p = .040). Caregivers in the control condition did not report significant changes in stress or depressive symptoms. CONCLUSIONS: Findings suggest that support from interventionists, including CHWs, might have alleviated stress and depressive symptoms during COVID-19, as well as improved asthma control during the pandemic.

Perceived Stress, Religiosity, and Substance Use Among African American and Latinx College Students with Asthma in the USA.

This study examined associations among perceived stress, religiosity, and substance use in African American and Latinx college students with asthma. Participants included 194 college students with asthma (18-20 years, 63.4% African American, 21.1% Latinx). Eligible students completed an online questionnaire that included measures of asthma control, perceived stress, religiosity, alcohol misuse, and last 30-day tobacco use and marijuana use. Over one-quarter (25.3%) of participants reported using tobacco and 31.9% reported using marijuana in the past 30 days. Perceived stress and religiosity were each independently associated with multiple indicators of substance use. Asthma control moderated associations between religiosity and tobacco use in the past 30 days (b = - .014, p = .002), such that the association between religiosity and tobacco use was stronger among those with better asthma control. Participant gender significantly moderated the association between perceived stress and alcohol misuse (b = - .099, p = .029); a stronger, positive association between stress and alcohol misuse was found among men. Students' perceived stress levels were associated with marijuana use in the past 30 days and high alcohol misuse. Religiosity was inversely linked to substance use. There is a need for healthcare providers to recognize and focus on substance use prevention specifically among African American and Latinx college students with asthma.

The COVID-19 pandemic: asthma control, tobacco use, and mental health among African American and Latinx college students.

OBJECTIVE: This study investigated the impact of COVID-19 on tobacco use and mental health in US African American and Latinx college students with asthma. Associations among asthma control, tobacco use, and mental health were also examined. METHODS: 105 African American and Latinx college students with asthma (18-23 years) completed two online questionnaires (June 2019-March 2020 for Time 1; August 2020-October 2020 for Time 2). Participants completed the Epidemic-Pandemic Impacts Inventory (measure of COVID-19 impact), Asthma Control Test, Generalized Anxiety Disorder scale, Patient Health Questionnaire (measure of depression), Perceived Stress Scale, and items related to tobacco use. RESULTS: Asthma control improved (t = -3.326, p = 0.001) from Time 1 to 2, and e-vapor product use decreased (χ2104 = 6.572, p = 0.010). COVID-19 impact was positively associated with students' symptoms of anxiety, depression, and perceived stress (B = 0.201, p < 0.001; B = 0.179, p < 0.001; and B = 0.199, p = 0.001, respectively) at Time 2. These results remained significant with the Benjamini-Hochberg correction. Asthma control at Time 1 was negatively associated with anxiety symptoms at Time 2 (B = -0.418, p = 0.023); however, associations with perceived stress (B = -0.514, p = 0.019) and all other tobacco product use (B = -0.233, p = 0.030) did not remain significant with the Benjamini-Hochberg correction. CONCLUSIONS: As hypothesized, a higher COVID-19 impact score was associated with students endorsing more mental health symptoms. Better control of asthma symptoms before the pandemic predicted fewer anxiety symptoms during the pandemic.

Caregiver Expressed Emotion and Pediatric Asthma: A Call for Culturally Specific Adaptations.

Background: Expressed emotion is the affective attitudes and behaviors of an individual toward another. In this preliminary study, we described expressed emotion among caregivers of children with asthma living in low-income urban area and evaluated its association with child asthma control. Methods: Forty-one children (90.2% African American/Black) and their caregivers participated. Measures included the Childhood Asthma Control Test and the Five-Minute Speech Sample coded for overall expressed emotion, emotional over-involvement, and criticism. Results: Most caregivers were rated borderline (31.7%) or high (48.8%) for expressed emotion, borderline (31.7%) or high (39.0%) for emotional overinvolvement, and low for criticism (73.2%). The association between criticism and asthma control neared statistical significance [U(Nlow = 30, NB/high = 11) = 100, z = -1.922, P = 0.055]. Conclusion: Findings suggest an examination into expressed emotion coding procedures for caregivers in low-income urban areas, and culturally specific adaptations may be necessary. Future research should confirm findings in a larger sample and consider how parental criticism affects children's asthma management.

African American Children's Racial Discrimination Experiences and Mental Health.

The current study examined how African American children's experiences of perceived personal racial discrimination and perceived vicarious racial discrimination were linked with depressive and anxiety symptoms, and whether there were significant sex differences in these relations. The sample included 73 African American children (48% male), ranging from 7 to 12 years of age (M = 8.82, SD = 2.06). Models specified children's personal discrimination and vicarious discrimination as predictors of depressive and anxiety symptoms. Nested model comparisons were also used to examine whether associations varied as a function of children's sex. The current study hypothesized that both forms of discrimination would be associated with greater anxiety and depressive symptoms. Findings indicated that children's personal racial discrimination significantly predicted greater child anxiety symptoms for both boys and girls. No significant sex differences emerged. Neither personal nor vicarious discrimination significantly predicted depressive symptoms. Our findings highlight that racialized experiences occur early in childhood and have important implications for children's mental health.

Family meals, positive versus negative emotion suppression, and emotional eating: examining adolescent-parent dyadic associations.

PURPOSE: The present study aimed to extend existing research by examining adolescent-parent dyadic associations among adaptive and maladaptive family meal characteristics, positive and negative emotion suppression, and emotional eating. METHOD: Participants included a community-based sample of adolescents and parents (N = 1646 dyads) who participated in the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating Study. Dyad members both completed measures assessing family meal characteristics (family meal importance beliefs, family mealtime television watching), emotion suppression, and emotional eating via online surveys. Actor-partner interdependence models were used to examine dyadic associations among the assessed family meal characteristics, positive and negative emotion suppression, and emotional eating. RESULTS: Multiple within-person (e.g., adolescent-adolescent, parent-parent), cross-dyad member (e.g., adolescent-parent, parent-adolescent), and divergent adolescent versus parent dyadic effects were identified that differed based on the extent to which participants suppressed positive versus negative affect. For example, whereas adolescents' stronger beliefs in the importance of frequent family meals were associated with lower levels of their own suppression of positive emotions and, in turn, lower levels of both their own and their parents' emotional eating, these mediational associations were only identified at the within-person (not cross-dyad member) level among parents. CONCLUSIONS: Collectively, these findings attest to the complexity of associations among the assessed risk and protective family meal characteristics, the suppression of differentially valenced emotions, and emotional eating that manifest at the adolescent-parent dyadic level. Findings also support the continued use of a family-based perspective to further the understanding of factors that are associated with emotional eating. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

What influences demand for cigars among African American adult cigar smokers? Results from a hypothetical purchase task.

African Americans (AA) have historically been targeted by the tobacco industry and have the highest rates of current cigar use among racial/ethnic groups in the U.S. Yet, there is limited evidence on other factors influencing cigar use. Amongst a sample of 78 AA current cigar (any type) smokers, log-linear regression models examined correlates of cigar demand obtained from a validated behavioral economic purchase task. Mean intensity, or cigar demand when free, was 6.68 cigars (standard deviation [SD]: 8.17), while mean breakpoint, or the highest price a participant was willing to pay, was $4.62 (SD: 3.88). Mean maximum daily expenditure, Omax was $15.20 (SD: 25.73) and Pmax, the price at Omax was $5.25 (SD: 3.95). Participants aged 21 to 30 years compared to those aged 18 to 20 years, those with higher levels of dependence, and females compared to males, had a significantly higher intensity. Participants with cannabis use above the sample median in the last 30 days (4 + days) had significantly higher intensity and Omax than those below the median. Further, participants with a high school education or more had a significantly lower intensity, breakpoint, and Omax than those with less than high school education. Individuals with income below the federal poverty line (FPL) also had a significantly lower breakpoint and Omax than those above. Finally, tobacco harm perceptions were inversely associated with Pmax. Stricter policies on cigar products, such as higher taxes and product-specific harm messaging, may have an immediate and sustained impact on health disparities related to cigar use. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adaptations to the RVA Breathes clinical trial due to the COVID-19 pandemic.

RVA Breathes, a community program to improve asthma management and care coordination among children living in a low-income, urban area, is being evaluated in a randomized clinical trial. In March 2020, RVA Breathes was converted to a remote program due to the COVID-19 pandemic; this report provides an update on the modifications made to the RVA Breathes trial. Additionally, given that families in the program have been disproportionally impacted by both COVID-19 and significant social unrest at both the local and national level, strategies used to enroll and engage families in the trial who bore disproportionately high burdens during this time period are outlined. Remote sessions (telephone or video) for families enrolled in the program prior to the onset of COVID-19 began in April 2020; enrollment of new families began remotely in July 2020 using adapted consent procedures. Baseline, intervention, and follow-up sessions were delivered either via the telephone or video depending upon family preference. Strategies were implemented to engage caregivers and children in completing measures over the telephone or video versus in person. Tangible intervention materials and participant payments were dropped off at family homes using contactless procedures. Our team was able to adapt and safely continue a large, community-based clinical trial, despite the increased health risks and social isolation mandates from the pandemic, by transitioning to a remote format. Challenges remain in determining whether RVA Breathes as a remote program has had the same impact on child asthma as the face-to-face interventions that comprised its original format.

A mindful yoga intervention for children with severe asthma: A pilot study.

INTRODUCTION: Children with severe asthma may benefit from non-pharmacological approaches to symptom management, yet little is known regarding the impact of mind-body approaches such as mindful yoga in this population. This pilot study examined the tolerability, feasibility, acceptability and immediate effects of a mindful yoga intervention in children with severe asthma. METHOD: Fifteen children ages 7-11 with severe asthma participated in a single mindful yoga session, followed by semi-structured interviews with the child and caregiver. Vital signs and pulmonary function tests were collected pre- and post-intervention. RESULTS: All children reported positive experiences and caregivers were generally supportive of their participation. One child experienced self-limited bronchoconstriction with asthma symptoms. There was no significant change in lung function or vital signs after the mindful yoga session. DISCUSSION: Our results warrant additional larger studies to evaluate the safety and benefits of mindful yoga in children with severe asthma.

A community-based asthma program: Study design and methods of RVA Breathes.

Disparities in pediatric asthma morbidity and healthcare utilization exist on the basis of race, ethnicity, environment, and income; interventions are needed to address these inequities. The following protocol describes an evidence-based intervention, RVA Breathes, designed to coordinate pediatric asthma care across family, home, community, and medical sectors. Community stakeholder feedback was utilized to refine the intervention specifically for the Richmond, Virginia community. The aims of this study are to assess the effect of RVA Breathes on asthma-related healthcare utilization, as well as secondary outcomes of asthma control, asthma symptoms, and quality of life. We will enroll 300 elementary school children from the Richmond City Public School system. Participants will be between the ages of 5-11, have a diagnosis of asthma, and have had an asthma exacerbation (as indicated by an asthma-related ED visit, hospitalization, unscheduled PCP visit, or use of systemic steroids) in the last two years. Participants will be randomized to one of three groups: asthma education + home environment remediation + school intervention, asthma education + home environment remediation, or a comparator condition. Data will be collected across one baseline research visit, four intervention sessions, and four follow-up research visits over the course of 18 months. A General Linear Mixed Model (GLMM) will be used to test primary aims. We expect the findings will provide support for coordination of asthma care across sectors. Further, we hope RVA Breathes will serve as a model of community-based pediatric asthma care.

School Nurses' Perspectives on Components of Asthma Programs to Address Pediatric Disparities.

OBJECTIVE: To use a community engaged, collaborative approach with school nurses working within an urban community, to develop recommendations for future school-based interventions targeting pediatric asthma disparities. METHODS: Open-ended survey data were collected from 33 nurses (77% of nurses in the school district) during a face-to-face monthly health services meeting. Questions asked nurses to estimate the proportion of students with asthma with the necessary forms and medications at school and to describe perceived barriers to having such forms and medications, and potential initiatives that could be implemented. A 30-min asthma education class was also piloted with school nurses, who then rated its acceptability and feasibility. Open-ended survey data were analyzed using thematic analysis. RESULTS: Nurses estimated that 12% of students with asthma had an asthma action plan, 19% had a medication release form, and 15% had medications at school (i.e. inhalers). Four themes emerged regarding barriers to asthma management in schools and strategies for promoting asthma management in schools: coordination of care, asthma education, access to care, and medication adherence. Nurses noted the need for education focused specifically on teaching inhaler technique, and better communication between schools, providers, and families. CONCLUSIONS: School nurses provided valuable information regarding specific barriers, as well as approaches to addressing these barriers in a future intervention. Findings suggest that a school-based intervention needs to address coordination among schools, parents, and medical providers, and will be optimally effective if it also addresses structural barriers.

Engaging with the Richmond Community to Reduce Pediatric Asthma Disparities: Findings from a Community-engaged Needs Assessment.

Childhood asthma disparities persist, with children living in low-income areas experiencing worse morbidity. We partnered with a community-academic research team and stakeholders to conduct a needs assessment to understand barriers and supports to asthma treatment. We convened a community advisory board, comprised of parents of children with asthma, youth with asthma, and members of key community organizations. Two focus groups with parents of children with asthma and four focus groups with youth with asthma were conducted, and a survey was administered to 100 parents. A visual mapping process was used to gather qualitative data about barriers, strategies, and outcomes, and allowed advisory board members to interpret focus group and survey data within the lived experiences of families. Focus group themes included parent stress/anxiety, concerns about school nurses, and lack of trust in providers. Findings from focus groups and surveys suggested that emergency department visits were not perceived negatively by families, although health providers and researchers generally view them as such. Public health implications include systemic changes that allow the healthcare system to address families' acute needs and worry. A community program focused on education and coordination among families, schools, and medical homes might improve asthma outcomes at the population level.

The impact of cumulative stress on asthma outcomes among urban adolescents.

INTRODUCTION: Many families living in low-income, urban areas experience a number of stressors (e.g., poverty, neighborhood stress, family functioning) that place adolescents at risk for worse asthma outcomes. Adolescents may face additional challenges (e.g., peer pressure, school stress) that add to their overall stress and influence their disease care and health outcomes. The current study examined the impact of a cumulative risk model of stressors including poverty, neighborhood stress, school stress, peer pressure, and caregiver-adolescent conflict on asthma outcomes (e.g., emergency department [ED] visits, asthma control, quality of life [QOL]) among urban adolescents (13-17 years). METHODS: Data were collected from 61 urban families of adolescents with asthma (54.1% female; 93.4% African American) in the United States. Caregivers and adolescents completed questionnaires assessing stressors and asthma outcomes separately during a research session. RESULTS: Cumulative risk was significantly associated with worse adolescent QOL and asthma control, and more ED visits. The cumulative risk index was also a more robust predictor of QOL and asthma control than any one individual predictor. Poverty, neighborhood stress, and school stress emerged as individual predictors of ED visits. Further, adolescents with well-controlled asthma had significantly lower neighborhood and school-related stress scores. CONCLUSIONS: Findings suggest that beyond the risk conferred by individual risk factors, an accumulation of stress can have an especially negative impact on asthma outcomes for urban adolescents. Future intervention work aimed at improving asthma outcomes should consider incorporating strategies for minimizing overlapping sources of stress in adolescents' daily lives.

Refining the Factor Structure of the All Aspects of Health Literacy Scale.

Objective: Although the All Aspects of Health Literacy Scale (AAHLS) is a commonly used measure of health literacy, the psychometric evaluation approach employed in its original validation is questionable. In this study, we evaluated the psychometric properties and factor structure of the AAHLS using widely-accepted analytic methods. Methods: We collected data from 393 students from a Mid-Atlantic university. Participants completed the AAHLS in an online format. We conducted an exploratory factor analysis (EFA) to determine whether a different factor/subscale structure emerged in this sample than in the original validation sample. We ran follow-up confirmatory factor analyses (CFAs). Results: The EFA suggested an 11-item, 4-factor model. The CFA of the 4-factor model had adequate model fit but evidenced several low item loadings, suggesting that several items did not perform well. We tested a modified 8-item, 3-factor model that had good fit and high item loadings. Compared to the original factor structure, the functional health literacy subscale was removed. Conclusions: The newly proposed 3-factor/subscale model with 8 items captures communicative health literacy and 2 separate aspects of critical health literacy. Further replication in other diverse samples is warranted to investigate the psychometric properties of the AAHLS, although we recommend use of the revised version over the original.

Executive functioning in pediatric cystic fibrosis: A preliminary study and conceptual model.

BACKGROUND: Research has shown that broad cognitive functioning in individuals with CF is intact. Specific executive functioning (EF) deficits have been identified, however, and adults with CF report more symptoms of ADHD than the general population. EF skills are critical to the management of a complex disease like CF although studies have not adequately examined EF mechanisms in CF. This manuscript (a) described EF in a small sample of children with CF, (b) summarized relations found between EF and psychosocial variables, and (c) presented a conceptual model by which to understand EF's impact on adherence in CF. METHODS: Data for this preliminary study were collected from 19 children with CF and their caregivers (ages, 6-18). Caregivers completed questionnaires assessing their child's physical and mental health, their own functioning, and overall family functioning. EF was measured using a parent-report rating scale. Patient health data were collected from the electronic medical record. RESULTS: This sample did not demonstrate elevated levels of EF impairment. Worse EF was related to poor family communication/cohesion, as well as higher treatment burden, worse lung function, poorer adherence, and older age. From these findings, a preliminary model was developed describing EF in the context of CF and adherence. CONCLUSIONS: Findings from this preliminary study suggest that the CF regimen and associated symptoms may overload otherwise adequate EF skills. Reducing disease burden and preventing burnout should be a focus of treatment. A better understanding of EF in CF and the impact on adherence would allow for better clinical management and effective design of interventions.

Interactive effects of family functioning and sleep experiences on daily lung functioning in pediatric asthma: An ecological momentary assessment approach.

Objectives: Children living in urban, underserved settings are at risk for experiencing sleep difficulties as well as poor asthma outcomes. The family is important for both asthma management and ensuring children are getting the necessary amount of sleep, but how family functioning and sleep patterns influence children's asthma remains unclear. Methods: Fifty-nine children (7-12 years old; 90% African American) diagnosed with asthma, and their primary caregivers, participated in this study. In a single research session, caregivers rated overall family functioning via the Family Assessment Device. Caregivers also completed daily diaries delivered via smartphone for a two-week period rating their children's daily sleep quantity and quality; a home-based spirometer (AM2) was used to assess children's pulmonary functioning across that same period. Two-level multilevel models tested associations among overall family functioning, children's sleep quality/quantity, and pulmonary functioning. Results: Child sleep quality, quantity, and general family functioning did not predict child pulmonary functioning directly. Family functioning and sleep quality interacted to predict children's pulmonary functioning; children with poor family functioning and bad/very bad sleep quality had the poorest levels of lung functioning. Conclusions: These findings highlight a subset of children who are at higher risk for poor lung functioning based on sleep quality and family functioning. Results may inform routine monitoring of family functioning and sleep difficulties at pediatric asthma visits and intervention strategies to augment children's lung functioning.