This research proposal investigates the efficacy of patient and family education for improving health outcomes in minority, inner-city children diagnosed with asthma. Drawing on CDC surveillance data, NHLBI/NAEPP clinical guidelines, and recent studies on inhaled corticosteroid therapy adherence, the paper identifies a gap in evidence-based educational interventions. A blinded, randomized controlled trial is proposed in which minority children and their caregivers, referred to an urban university teaching hospital, are randomized to standard care or standard care plus an intensive three-session education program adapted from a French pediatric pulmonology study. Outcome measures include the Pediatric Asthma Quality of Life Questionnaire, FEV1 lung function testing, Fitbit activity tracking, and rates of emergency department visits, hospital admissions, and missed school days.
The paper demonstrates strong evidence-to-design bridging: each element of the proposed RCT — blinding, randomization, inclusion/exclusion criteria, outcome instruments — is justified by citing limitations of predecessor studies (notably Julian et al. and Mosnaim et al.). Rather than simply describing what will be done, the author explains why each design choice corrects a weakness in the existing evidence base.
The paper follows a classic research proposal format: an introduction establishing significance and health disparities, a focused literature review synthesizing two key prior studies, a theoretical framework section grounding the intervention in Peplau's nursing model, a detailed methods section covering design, participants, ethics, and intervention protocol, a measures section justifying each outcome instrument, and a timeline section with explicit power calculations and statistical plan. This structure maps cleanly onto standard IRB and grant-proposal conventions.
The 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) reduction or elimination of environmental triggers, (3) patient and family education, and (4) long-term disease management using comprehensive pharmacotherapy (NHLBI & NAEPP, 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 investigates 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 2010 U.S. Census data, this represented almost 7 million children. Asthma attacks among children were also very common, with approximately 56.1% of children between birth and 17 years of age reporting an asthma attack during the same period (Moorman, Person, Zahran, & CDC, 2013). In 2007, 185 asthma attacks resulted in the death of a child (AAAAI, 2014). An average of $1,039 was spent annually per child diagnosed with asthma (CDC, 2012), translating into approximately $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 disproportionately (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, 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 a 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 occurred one month later. Outcome measures were collected using a pretest/posttest study design without a control group, with the posttest taking place four months after the initial consultation.
The quality of life for the children enrolled in the study, who were between 5 and 11 years of age, did not improve significantly, but it did improve significantly 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 of reducing health disparities. Mosnaim and colleagues (2014) revealed that ICT knowledge predicted treatment compliance in minority children, while Julian and colleagues (2014) found that an education-based intervention could improve a number of outcome measures among children in France. An education-based intervention aligns 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 six helping roles when interacting with patients: stranger, resource person, teacher, leader, surrogate, counselor, and — added later — technical expert.
The helping roles proposed by Peplau that are most relevant to an education-based intervention for improving the health outcomes of children with asthma are resource person, teacher, leader, counselor, and technical expert (Coury, Martsolf, Drauker, & Strickland, 2008). The resource role provides the patient and caregivers with evidence-based information about asthma and its management, while the teacher role encourages retention of the information provided. The nurse as leader helps create a treatment plan, including the steps to be taken if the child suffers an asthma attack. As counselor, the nurse facilitates and encourages the patient and caregiver to become proactive about exploring asthma independently and serves as a sounding board for any issues that may arise about treatment and conflicting information.
Based on this analysis, the intervention studied by Julian and colleagues (2014) may prove effective within an inner-city setting in the United States. The target demographic will be minority children and caregivers appearing for the first time at an urban university teaching hospital with a school referral for an asthma evaluation.
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