The Capstone ePortfolio in an Undergraduate Public Health Program: Accreditation, Assessment, and Audience.

The Bachelor of Science in Public Health (BSPH) degree program at the University of North Carolina at Charlotte (UNC Charlotte) was launched in 2007, and was initially accredited by the Council on Education for Public Health in 2009. We admit approximately 40-45 students each fall to the upper division major, through a competitive admissions process. During the junior and senior years, BSPH majors complete a core set of required courses including internship; 18 credit hours of restricted electives; and any minor offered by the university (except public health). During 2014-2015, the Department of Public Health Sciences was one of five campus units supported by UNC General Administration to pilot the use of ePortfolios as a tool to help students integrate learning across the courses that make up the major. The pilot program continued for 2 additional years, to promote enduring faculty efforts. We subsequently outline the development and implementation of ePortfolio pedagogy in the BSPH program at UNC Charlotte, including preliminary assessment of outcomes the past 3 years. The adoption of ePortfolios has been instrumental in students' educational experiences for over 2 decades. The Association of American Colleges and Universities (AAC&U) has advocated that "ePortfolios allow faculty and other educational professionals to help students organize their learning; preserve the variety of forms in which their learning occurs; and reflect upon their learning." We have learned that effective student ePortfolios do not arise in a vacuum. In collaboration with like-minded campus colleagues including those associated with the university's Communication Across the Curriculum program, we have encountered contributing forces related to the process of "collection, selection, and reflection" including intentional assignments that yield effective student artifacts; and authentic feedback to students through adoption and modification of the AAC&U VALUE rubrics. We conclude that internal and external forces drive the development of ePortfolio content; students embrace opportunities to document learning when those opportunities are structured; the development of the ePortfolio is relational-consistent with student attributes; and ePortfolios enable evidence-based approaches to meet accreditation demands, assessment needs, and workforce expectations.

Effects of Symptom Perception Interventions on Trigger Identification and Quality of Life in Children with Asthma.

BACKGROUND: Management of individual triggers is suboptimal in practice. In this project, we investigated the impact of symptom perception interventions on asthma trigger identification and self-reported asthma quality of life. METHODS: Children with asthma (n=227) participated in three asthma education sessions and then were randomized first to one of three home monitoring conditions (symptom monitoring and peak flow training with feedback, peak flow training without feedback, or no peak flow training) and then subsequently to one of three resistive load discrimination training conditions (signal detection training with feedback, signal detection training without feedback, or no training). Triggers were reported at enrollment, following home monitoring, and following discrimination training; quality of life was measured after home monitoring and after resistive load testing. RESULTS: Symptom perception interventions resulted in increases in reported triggers, which increased reliably as a function of home monitoring, and increased further in participants who completed discrimination training with feedback. Increases in the number of reported asthma triggers were associated with decreases in quality of life. DISCUSSION: Patients may benefit from strategies that make trigger-symptom contingencies clear. Complementary strategies are needed to address changes in the perceived burden of asthma which comes from awareness of new asthma triggers.

Reliability and predictors of resistive load detection in children with persistent asthma: a multivariate approach.

OBJECTIVE: Resistive load detection tasks enable analysis of individual differences in psychophysical outcomes. The purpose of this study was to determine both the reliability and predictors of resistive load detection in children with persistent asthma who completed multiple testing sessions. METHODS: Both University of North Carolina (UNC) Charlotte and Ohio University institutional review boards approved the research protocol. The detection of inspiratory resistive loads was evaluated in 75 children with asthma between 8 and 15 years of age. Each child participated in four experimental sessions that occurred approximately once every 2 weeks. Multivariate analyses were used to delineate predictors of task performance. RESULTS: Reliability of resistive load detection was determined for each child, and predictors of load detection outcomes were investigated in two groups of children: those who performed reliably in all four sessions (n = 31) and those who performed reliably in three or fewer sessions (n = 44). Three factors (development, symptoms, and compliance) accounted for 66.3% of the variance among variables that predicted 38.7% of the variance in load detection outcomes (Multiple R = 0.62, p = 0.004) and correctly classified performance as reliable or less reliable in 80.6% of the children, χ(2)(12) = 28.88, p = 0.004. CONCLUSIONS: Cognitive and physical development, appraisal of symptom experiences, and adherence-related behaviors (1) account for a significant proportion of the interrelationships among variables that affect perception of airflow obstruction in children with asthma and (2) differentiate between children who perform more or less reliably in a resistive load detection task.

Effects of feedback on the perception of inspiratory resistance in children with persistent asthma: a signal detection approach.

OBJECTIVE: Accurate perception of asthma episodes increases the likelihood that they will be managed effectively. The purpose of the study was to examine the effect of feedback in a signal detection task on perception of increased airflow obstruction in children with persistent asthma. METHODS: The effect of feedback training on the perception of resistive loads was evaluated in 155 children with persistent asthma between 8 and 15 years of age. Each child participated in four experimental sessions that occurred approximately once every 2 weeks, an initial session followed by three training sessions. During the initial session, the threshold resistance to breathing was determined for each child. Subsequently, each child was randomly assigned to one of two resistive load training conditions in a signal detection paradigm: training with immediate performance feedback or training with no performance feedback. RESULTS: The threshold resistance to breathing, determined in the initial session, was equivalent between groups. Children in the feedback condition discriminated more accurately between both the presence and the absence of increases in the resistance to breathing (206 [48] versus 180 [39] correct responses, p < .001), and differences over time between groups increased reliably as a function of training (165 [40] versus 145 [32] correct responses, p < .001). Response times and confidence ratings were equivalent between groups, and no differences in breathing patterns were observed between conditions. CONCLUSIONS: Feedback training results in improved perception of respiratory sensations in children with asthma, a finding with implications for strategies of asthma self-management.

Effect of increased blood levels of ß-endorphin on perception of breathlessness.

BACKGROUND: Although opioid receptors are expressed broadly in the CNS and in peripheral sensory nerve endings including bronchioles and alveolar walls of the respiratory tract, it is unknown whether the modulatory effect of endogenous opioids on breathlessness occurs in the CNS or in the peripheral nervous system. The purpose of this investigation was to examine whether increased blood levels of ß-endorphin modify breathlessness by a putative effect of binding to peripheral opioid receptors in the respiratory tract. METHODS: Twenty patients with COPD (10 women and 10 men; age, 70 ± 8 years) inspired through resistances during practice sessions to identify an individualized target load that caused ratings of intensity and unpleasantness of breathlessness ≥ 50 mm on a 100-mm visual analog scale. At two interventions, blood levels of ß-endorphin and adrenocorticotropic hormone (ACTH) were measured, ketoconazole (600 mg) or placebo was administered orally, and patients rated the two dimensions of breathlessness each minute during resistive load breathing (RLB). RESULTS: By inhibiting cortisol synthesis, ketoconazole led to significant increases in ß-endorphin (mean change, 20% ± 4%) and ACTH (mean change, 21% ± 4%) compared with placebo. The intensity and unpleasantness ratings of breathlessness and the endurance time during RLB were similar in the two interventions. CONCLUSIONS: The previously demonstrated modulatory effect of endogenous opioids on breathlessness appears to be mediated by binding to receptors within the CNS rather than to peripheral opioid receptors in the respiratory tract. An alternative explanation is that the magnitude of the ß-endorphin response is inadequate to affect peripheral opioid receptors. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01378520; URL: www.clinicaltrials.gov.

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.

BACKGROUND: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

The Certified Asthma Educator: The United States Experience.

Asthma is responsible for significant healthcare costs in the United States. Although advances in pharmacology and environmental science have provided many opportunities to improve asthma control, asthma remains a major cause of missed school days, acute care visits, and hospitalizations. Patient education is a key component of asthma care. The National Asthma Educator Certification Board was established in February 2000 and charged with the mission of "promoting optimal asthma management and quality of life for individuals with asthma, their families and communities by advancing excellence in asthma education through the certified asthma educator process." This study was performed to describe the workforce of certified asthma educators (AE-Cs®) by surveying a sample of educators who completed the recertification process. AE-Cs® who had completed the recertification process were invited to participate in an anonymous online survey. Sixty five of 135 (48%) recertificants completed the survey. The primary training of respondents was in respiratory therapy (51.6%) and nursing (42.2%). Respondents were primarily female (92.3%) and Caucasian (95.4%). The majority worked in specialty care outpatient (59.3%) or hospital inpatient (40.7%) settings. Twenty percent reported an increase in job responsibilities as a result of achieving their initial certification as an AE-C®. Most AE-Cs® have their basic training in either respiratory therapy or nursing. The workforce of AE-Cs® does not reflect the racial or ethnic percentages seen in the asthma population in the United States. More educators are needed to serve the growing numbers of individuals with asthma. Achievement of certification as an AE-C® resulted in additional job responsibilities in 20% of survey respondents.

Descriptors of breathlessness in children with persistent asthma.

BACKGROUND: In adult patients, the consistent use of language to describe dyspnea enhances patient-provider communication and contributes to diagnostic and therapeutic decisions. The objective of this research was to determine whether pediatric patients similarly display consistency in the language used to describe "uncomfortable awareness of breathing." METHODS: One hundred children between the ages of 8 and 15 years with moderate to severe persistent asthma enrolled in an asthma education research program completed questionnaires regarding descriptors of asthma on each of two occasions. In addition to the breathlessness questionnaires, demographic information, self-reported asthma severity, ED visits, missed school days, anthropometrics, and spirometry were obtained for each participant. RESULTS: Children were reliable in their choice of the descriptors that they applied to their breathing discomfort across two occasions, and they selected the same descriptors that were used by adults with asthma in previous studies. Children with greater self-reported asthma severity endorsed more descriptors to characterize breathing discomfort than did children with less severe asthma, but no differences were found among children based on demographic or anthropometric variables. CONCLUSIONS: Children with moderate to severe persistent asthma are reliable in their choice of descriptors of breathlessness. Knowledge of their experience of symptoms may be helpful clinically in the assessment and management of asthma.

Do asthma patients prefer to monitor symptoms or peak flow?

We administered a 65-item survey to patients to assess preference of symptoms and peak flow to detect worsening asthma and to collect information about asthma triggers, asthma knowledge sources, and barriers to peak flow meter use. It was completed by 139 asthma patients. Survey responses were comparable for adult and pediatric patients and for those who owned peak flow meters and those who did not. But patients who owned a peak flow meter reported more severe asthma than others. On average, the patients preferred symptoms to peak flow for assessing worsening asthma. It is likely that the preference for symptom over peak flow monitoring was effort related: Patients preferred symptom monitoring because it was the easier of the two to conduct.

A model for integrating strategic planning and competence-based curriculum design in establishing a public health programme: the UNC Charlotte experience.

INTRODUCTION: The University of North Carolina at Charlotte, a doctoral/research-intensive university, is the largest institution of higher education in the Charlotte region. The university currently offers 18 doctoral, 62 master's and 90 baccalaureate programmes. Fall 2008 enrolment exceeded 23,300 students, including more than 4900 graduate students. The university's Department of Health Behavior and Administration was established on 1 July 2002 as part of a transformed College of Health & Human Services. CASE DESCRIPTION: In 2003, the Department initiated a series of stakeholder activities as part of its strategic planning and programmatic realignment efforts. The Department followed an empirically derived top-down/bottom-up strategic planning process that fostered community engagement and coordination of efforts across institutional levels. This process culminated in a vision to transform the unit into a Council on Education for Public Health accredited programme in public health and, eventually, an accredited school of public health. To date, the Department has revised its Master of Science in health promotion into an Master of Science in Public Health programme, renamed itself the Department of Public Health Sciences, launched a Bachelor of Science in Public Health major, laid plans for a doctoral programme, and received accreditation from the Council on Education for Public Health as a public health programme. Furthermore, the campus has endorsed the programme's growth into a school of public health as one of its priorities. DISCUSSION AND EVALUATION: It is only through this rigorous and cyclical process of determining what society needs, designing a curriculum specifically to prepare graduates to meet those needs, ensuring that those graduates meet those needs, and reassessing society's needs that we can continue to advance the profession and ensure the public's health. Community stakeholders should be active contributors to programme innovation. Lessons learnt from this process include: being connected to your community and knowing its needs, being responsive to your community, remembering that process is as important as product, and preparing for success. CONCLUSION: The efforts reported here can be informative to other institutions by exemplifying an integrated top-down/bottom-up process of strategic planning that ensures that a department's degree programmes meet current needs and that students graduate with the competences to address those needs.

Home monitoring in asthma self-management.

Peak flow monitoring of asthma came into vogue with the advent of asthma self-management programs. Because it offered an objective way to gauge asthma severity, it promised improvement in the accuracy of asthma monitoring over that attainable by symptom monitoring. This promise has not been fulfilled. The ensuing years have witnessed a debate concerning the relative merits of symptom and peak flow monitoring. The debate has focused both on the degree to which peak flow and symptom scores are related to one another and on the relative effectiveness of symptom and peak flow monitoring for asthma control. We review research relating to these topics. The work shows that the strength of the relationship between peak flow and symptoms is low to moderate and varies between individuals and that benefits of peak flow monitoring in asthma self-management provide, at best, no more than a small increment in effectiveness beyond that afforded by symptom monitoring.

Guidelines for mechanical lung function measurements in psychophysiology.

Studies in psychophysiology and behavioral medicine have uncovered associations among psychological processes, behavior, and lung function. However, methodological issues specific to the measurement of mechanical lung function have rarely been discussed. This report presents an overview of the physiology, techniques, and experimental methods of mechanical lung function measurements relevant to this research context. Techniques to measure lung volumes, airflow, airway resistance, respiratory resistance, and airflow perception are introduced and discussed. Confounding factors such as ventilation, medication, environmental factors, physical activity, and instructional and experimenter effects are outlined, and issues specific to children and clinical groups are discussed. Recommendations are presented to increase the degree of standardization in the research application and publication of mechanical lung function measurements in psychophysiology.