Improving Health Outcomes for Inner-City Children with Asthma
Improving Health Outcomes for Inner-City Children with Asthma
Centers for Disease Control and Prevention (CDC) engages in active surveillance of childhood asthma because it is prevalent, contributes significantly to childhood morbidity, and imposes an economic burden on families (CDC, 2012). The main recommendations for diagnosing and managing asthma by the National Heart, Lung, and Blood Institute (NHLBI) and the National Asthma Education and Prevention Program (NAEPP) at the National Institutes of Health are: (1) objective measures of lung function, (2) reduce or eliminate environmental triggers, (3) patient and family education, and (4) long-term disease management using comprehensive pharmacotherapy (2007, p. 1). Not only are these recommendations important for limiting the disease burden during childhood, but recent studies have begun to uncover links between chronic childhood respiratory problems and the development of chronic obstructive pulmonary disease (COPD) in older adults (Guerra, Stern, & Morgan, 2013).
Among the children who suffer from asthma, minority children tend to have the worst outcomes (Moorman, Person, Zahran, & CDC, 2013). This is due in part to children and adolescents having poor knowledge about the use and benefits associated with inhaled corticosteroid therapy (Mosnaim et al., 2014). Patient and family education about asthma and treatment regimens therefore represents one important method for reducing not only disease burden, but also health disparities suffered by U.S. children. This research proposal will therefore investigate the efficacy of family education for reducing asthma-associated morbidity and economic burden.
Among all U.S. children, 9.4% have reported current asthma (Howden & Meyer, 2011). Based on the 2010 U.S. Census data this represented almost 7 million children. Asthma attacks among children were also very common, with approximately 56.1% of these children, between the ages of birth and 17-years, reporting an asthma attack during the same period (Moorman, Person, Zahran, & CDC, 2013). In 2007, 185 asthma attacks resulted in the death of the child (AAAAI, 2014). An average of $1,039 was spent annually per child diagnosed with asthma (CDC, 2012), which translates into about $7.2 billion overall. In addition, these children missed 10.5 million days of school in 2008 as a result of their disease (CDC, 2012). When asthma prevalence is examined along racial lines, minorities tend to suffer more (Moorman, Person, Zahran, & CDC, 2013). Close to 17% of non-Hispanic African-American children suffered from asthma in 2009 and between 2001 and 2009 the prevalence of asthma within this demographic nearly doubled (AAAAI, 2014). Poverty and access to health care services therefore play a significant role in determining asthma prevalence.
Efforts to improve health outcomes for minority children with asthma have varied greatly. A recent randomized, controlled trial (RCT) tested the efficacy of peer support and peer messages sent to MP3 players for increasing inhaled corticosteroid therapy (ICT) compliance among minority adolescents, but found no benefit (Mosnaim et al., 2013). When the same research group examined a number of possible predictive factors, including demographic variables, disease history, exacerbations, depression, asthma knowledge, ICT knowledge, and ICT self-efficacy, only older age and less ICT knowledge were significant predictors of low ICT adherence (Mosnaim et al., 2014). These results are consistent with the NHLBI/NAEPP (2007) guidelines recommending patient education as an important disease management strategy with the potential to reduce health disparities.
As Julian and colleagues (2014) noted in their recent research paper, very few studies have examined the efficacy of patient and family education on health outcomes. Accordingly, they studied the impact of a therapeutic education intervention on outcome variables, including child quality of life, caregiver quality of life, treatment compliance, lung function testing, asthma attack incidence, emergency department visits, hospital admissions, missed school days, and parent sick days due to a sick child. The intervention took place in the pediatric pulmonary department at the Clermont-Ferrand teaching hospital in France and consisted of three phases: (1) disease description and written action plan for asthma attacks during the first consultation, (2) individual educational diagnosis by a doctor with patient and caregiver, and (3) group consultation with up to four families and two doctors for the purpose of providing detailed descriptions of asthma pathophysiology, symptomology, triggers, attacks, and treatments. The first two phases occurred on the same day and the third phase a month later. Outcome measures were collected using a pretest and posttest study design without a control, with the posttest taking place four months after the initial consultation.
The quality of life for the children enrolled in the study, which were between the ages of 5- and 11-years, did not improve significantly, but it did for the parents (p < 0.001) (Julian et al., 2014). In addition, emergency department visits (p = .02), unscheduled clinic visits (p < .001), and school absenteeism (p = .009) all declined significantly, while lung function improved (p = .05). The results of this study further support the use of patient and family education for improving the health outcomes of children suffering from asthma.
The findings of Julian et al. (2014) and Mosnaim et al. (2014) suggest that the health outcomes of children with asthma can be significantly improved through patient and caregiver education, which may be an effective means through which health disparities can be reduced. Mosnaim and colleagues (2014) revealed that ICT knowledge predicted treatment compliance in minority children, while Julian and colleagues (2014) discovered an education-based intervention could improve a number of outcome measures among children in France. An education-based intervention would align well with Hildegard Peplau's nursing theory of interpersonal relationships (Coury, Martsolf, Drauker, & Strickland, 2008). Peplau proposed that a nurse can adopt one or more of five helping roles when interacting with patients: stranger, resource person, teacher, leader, surrogate, and counselor. A sixth helping role was added later, which was technical expert.
The helping roles proposed by Peplau that seem relevant to an education-based intervention for improving the health outcomes of children suffering from asthma are resource person, teacher, leader, counselor, and technical expert (Coury, Martsolf, Drauker, & Strickland, 2008). The resource role would provide the patient and caregivers with evidence-based information about asthma and its management, while the teacher role would encourage the retention of the information provided. The nurse as leader would help create a treatment plan, including the steps that should be taken if the child suffers an asthma attack. As counselor, the nurse would facilitate and encourage the patient and caregiver to become proactive about exploring asthma individually and act as a sounding board for any issues that may arise about treatment and conflicting information.
Based on the above analysis the intervention studied by Julian and colleagues (2014) may prove to be effective within an inner city setting in the United States. The target demographic will be minority children and caregivers appearing for the first time in an urban university teaching hospital with a school referral for an asthma evaluation.
Methods and Procedures
Julian and colleagues (2014) used a quasi-experimental approach with a pretest/posttest study design. No control group was utilized, which limited the generalizability of the study's findings. The study being proposed here will increase experimental rigor by randomizing the families of children with newly diagnosed asthma to either standard care or standard care plus an intensive education component. All participants will be informed of the overall nature of the study, i.e., the improvement of treatment compliance, but the control group will be blinded to the nature of the intervention. In addition, the pulmonology care team performing the initial evaluation will be blinded to group assignment, as will the pulmonology care team performing posttest lung function tests. The study design being proposed is therefore a blinded, randomized, controlled trial.
Children and their caregivers being referred for the first time to a pediatric pulmonologist for an asthma evaluation will be asked to participate in the study. The inclusion criteria for the child will be a diagnosis of persistent asthma, age between 5- and 17-years, racial or ethnic minority, and family income at or below 200% of the poverty line as determined by the U.S. Department of Health and Human Services (HHS) (2012). For a family of four this would be an annual income of $46,100 in 2012/2013. The exclusion criteria would be the child or caregiver suffering from a comorbid condition that would preclude them from participating in the study, such as a cancer diagnosis or time constraints. The other comorbid conditions that would preclude the child's inclusion in the study would be cystic fibrosis, congenital heart disease, or bronchopulmonary dysplasia.
Since an intensive educational intervention is not considered a standard therapeutic approach within the United States and the children in both the intervention and control groups will still receive standard asthma treatment, no ethical issues exist. All caregivers will be asked to sign an informed consent form and consent will be required before being allowed to participate in the study. Institutional review board approval for this human subjects study will be obtained prior to…