Giselle Mosnaim

Use of MP3 players to increase asthma knowledge in inner-city African-American adolescents.

Background: Low-income African-American adolescents suffer a disproportionate burden of asthma morbidity.Purpose: To evaluate the ability of our intervention, the Adolescents’ Disease Empowerment and Persistency Technology (ADEPT) for asthma, to increase asthma knowledge in our target population.Methods: This was a 14-week (2-week run-in and 12-week treatment) randomized, double-blind, placebo-controlled pilot study in which 28 inner-city African-American adolescents with asthma, between 10 and 18 years of age, were randomized to receive (1) celebrity asthma messages (experimental group), or (2) general health messages (control group) between music tracks on an MP3 player. The asthma messages were recorded by famous athletes, musicians, and other celebrities popular among this group of teenagers. Asthma knowledge, assessed by the ZAP Asthma Knowledge instrament, was collected pre- and post-intervention.Results: Mean improvement in ZAP score was significantly higher in the experimental group (8.1%, SD 7.2%) than the control group (0.4%, SD 7.2%) (p = 0.05).Conclusion: These findings suggest that this may be an innovative and promising new approach to improving asthma outcomes in this difficult-to-reach population.

Factors associated with levels of adherence to inhaled corticosteroids in minority adolescents with asthma.

BACKGROUND Nonadherence to inhaled corticosteroids (ICS) is a significant risk factor for poor asthma outcomes in minority adolescents with persistent asthma. OBJECTIVE To identify factors associated with nonadherence to daily ICS in this target population. METHODS Adolescents 11 to 16 years old, self-identified as African American or Hispanic, diagnosed with persistent asthma and with an active prescription for daily ICS were invited to participate. Participant adherence to ICS was electronically measured during 14 days. Concurrently, participants completed the following assessments: demographic information, asthma history, asthma control, asthma exacerbations, media use, depression, asthma knowledge, ICS knowledge, and ICS self-efficacy. Of the 93 subjects, 68 had low (<48%) adherence and 25 had high (>48%) adherence. RESULTS Older age and low ICS knowledge each were associated with low (≤48%) adherence (P < .01 for the 2 variables). CONCLUSION Older age and low ICS knowledge each may be associated with poor adherence to ICS in minority adolescents with persistent asthma. Although older age often is associated with the assignment of increased responsibility for medication-taking behavior, it may not be associated with increased adherence. Continued and expanded efforts at promoting asthma education and specifically knowledge of ICS may increase adherence to ICS.

The Impact of Peer Support and mp3 Messaging on Adherence to Inhaled Corticosteroids in Minority Adolescents with Asthma: A Randomized, Controlled Trial

BACKGROUND Poor adherence to inhaled corticosteroids (ICS) is a critical risk factor contributing to asthma morbidity among low-income minority adolescents. OBJECTIVE This trial tested whether peer support group meetings and peer asthma messages delivered via mp3 players improved adherence to ICS. METHODS Low-income African American and/or Hispanic adolescents, ages 11-16 years old, with persistent asthma, and poor (≤ 48%) adherence to prescription ICS during the 3-week run-in were randomized to intervention or attention control groups (ATG) for the 10-week treatment. During treatment, the intervention arm subjects participated in weekly coping peer group support sessions and received mp3 peer-recorded asthma messages that promoted adherence. The ATG participated in weekly meetings with a research assistant and received an equivalent number of mp3 physician-recorded asthma messages. Adherence was measured by using self-report and the Doser CT, an electronic dose counter. The primary outcome was the difference in adherence at 10 weeks between the 2 arms. RESULTS Thirty-four subjects were randomized to each arm. At 10 weeks, no statistical difference in objectively measured adherence could be detected between the 2 arms when adjusting for baseline adherence (P = .929). Adherence declined in both groups over the course of the active treatment period. In both study arms, self-reported adherence by participants was significantly higher than their objectively measured adherence at week 10 (P < .0001). CONCLUSION Improving medication adherence in longitudinal studies is challenging. Peer support and mp3-delivered peer asthma messages may not be of sufficient dose to improve outcomes.

Behavioral Interventions to Improve Asthma Outcomes for Adolescents: A Systematic Review.

BACKGROUND Factors at multiple ecological levels, including the child, family, home, medical care, and community, impact adolescent asthma outcomes. OBJECTIVE This systematic review characterizes behavioral interventions at the child, family, home, medical system, and community level to improve asthma management among adolescents. METHODS A systematic search of PubMed, SCOPUS, OVID, PsycINFO, CINAHL, and reference review databases was conducted from January 1, 2000, through August 10, 2014. Articles were included if the title or abstract included asthma AND intervention AND (education OR self-management OR behavioral OR technology OR trigger reduction), and the mean and/or median age of participants was between 11 and 16 years. We compared populations, intervention characteristics, study designs, outcomes, settings, and intervention levels across studies to evaluate behavioral interventions to improve asthma management for adolescents. RESULTS Of 1230 articles identified and reviewed, 24 articles (21 unique studies) met inclusion criteria. Promising approaches to improving adherence to daily controller medications include objective monitoring of inhaled corticosteroid adherence with allergist and/or immunologist feedback on medication-taking behavior and school nurse directly observed therapy. Efficacy at increasing asthma self-management skills was demonstrated using group interactive learning in the school setting. This systematic review is not a meta-analysis, thus limiting its quantitative assessment of studies. Publication bias may also limit our findings. CONCLUSIONS Novel strategies to objectively increase controller medication adherence for adolescents include allergist and/or immunologist feedback and school nurse directly observed therapy. Schools, the most common setting across studies in this review, provide the opportunity for group interactive learning to improve asthma knowledge and self-management skills.

Evaluation of the Fight Asthma Now (FAN) program to improve asthma knowledge in urban youth and teenagers

BACKGROUND School-based asthma education programs targeting disadvantaged youth and teens with asthma are lacking. OBJECTIVES To assess the impact of the Fight Asthma Now (FAN) educational program among 2 populations of predominantly low-income minority students: youth (3(rd)-6(th) graders) and teens (7(th)-8(th) graders). METHODS Chicago-area elementary schools were invited to participate in this stratified 2-arm study. Eligible schools were assigned to participate either in the intervention or in the control arm. Within each participating school, eligible students were recruited and grouped (stratified by grade and age) to form teen or youth classes. Participants completed a pre- and post-intervention asthma knowledge questionnaire and observation for spacer technique competency. The treatment group received the FAN curriculum between the evaluations. RESULTS A sample of 26 low-income, predominantly minority-serving schools was recruited. Most participating schools were randomized in a 3:1 ratio to form 25 youth classes (19 intervention and 6 control group) and 16 teen classes (11 intervention and 5 control group), resulting in 275 vs 69 youth and 141 vs 51 teens in the intervention and control groups, respectively. Stratified analyses were performed, and clustering within the school and class was taken into consideration in analyses. Multilevel models adjusting for school, class, ethnicity, sex, and pretest score indicate that the FAN intervention significantly increased both knowledge and spacer competency test scores, among both the youth and teen participants (P = .011 with respect to knowledge score among teen students, P < .0001 for all other cases). CONCLUSIONS This study suggests that FAN significantly increases asthma knowledge and spacer technique competency within this high-risk population.

Validation of the Spanish and English versions of the asthma portion of the Brief Pediatric Asthma Screen Plus Among Hispanics

BACKGROUND The health and health care needs of non-English-speaking Hispanic families with children are poorly understood, in part because they are often excluded from research owing to language barriers. Instruments that are valid in English and Spanish are necessary to accurately evaluate the magnitude of asthma prevalence and morbidity among Hispanics. OBJECTIVE To establish the sensitivity and specificity of the English and Spanish versions of the asthma portion of the Brief Pediatric Asthma Screen Plus (BPAS+) in a low-income Hispanic population. METHODS The validation sample consisted of 145 children whose parents completed the BPAS+ in Spanish and 78 whose parents completed it in English. Bilingual clinicians conducted the examinations on which the clinical assessments were based. We compared the BPAS+ results with the clinical assessment findings to determine the sensitivity and specificity of the BPAS + among Hispanics in terms of identifying children who warrant further medical evaluation for asthma. RESULTS The sensitivity and specificity of the asthma portion of the Spanish BPAS+ were 74% and 86%, respectively. The sensitivity and specificity of the asthma portion of the English BPAS+ were 61% and 83%, respectively. CONCLUSIONS The asthma portion of the BPAS+, a valid screen for identifying children who are in need of further evaluation for potentially undiagnosed asthma, is valid for low-income Hispanics in Spanish and English. As the Hispanic population continues to grow, it is imperative that researchers have English and Spanish instruments that are valid for this population.

Adding montelukast to fluticasone propionate/salmeterol for control of asthma and seasonal allergic rhinitis

Limited information exists comparing fluticasone propionate/salmeterol combination (FSC) versus montelukast (MON) in patients with coexistent asthma and allergic rhinitis. The purpose of this study was to compare the addition of MON to patients receiving FSC on asthma control while experiencing asthma and allergy symptoms. Additionally, the effect of fluticasone propionate aqueous nasal spray (FPANS) and MON were assessed in allergic rhinitis control. Symptomatic patients (n = 1385) with asthma and seasonal allergic rhinitis were randomized to receive FSC, 100/50 micrograms twice daily; FSC twice daily + FPANS, 200 micrograms once daily; FSC twice daily + MON, 10 mg once daily; or MON once daily for 4 weeks during the allergy pollen season. Patients recorded peak expiratory flow, rescue albuterol use, and asthma and rhinitis symptoms. No additional improvements in overall asthma control were seen when MON was added to FSC. Treatment with FSC produced significant (p < 0.001) improvements in all clinical and patient-reported measures versus MON. FSC + FPANS was superior to FSC + MON (p < or = 0.001) in improving daytime and nighttime total nasal symptom scores. Adverse events were similar. In patients with asthma and allergic rhinitis, adding MON to FSC provided no additional benefit in asthma control. FSC resulted in superior improvement in asthma control compared with MON. FPANS also provided superior nasal symptom control versus MON in allergic patients treated with FSC for asthma. Optimal disease control in patients with asthma and allergic rhinitis should be achieved by the most effective therapy directed toward each disease component.

Engaging stakeholders to design a comparative effectiveness trial in children with uncontrolled asthma

AIM To present the methods and outcomes of stakeholder engagement in the development of interventions for children presenting to the emergency department (ED) for uncontrolled asthma. METHODS We engaged stakeholders (caregivers, physicians, nurses, administrators) from six EDs in a three-phase process to: define design requirements; prototype and refine; and evaluate. RESULTS Interviews among 28 stakeholders yielded themes regarding in-home asthma management practices and ED discharge experiences. Quantitative and qualitative evaluation showed strong preference for the new discharge tool over current tools. CONCLUSION Engaging end-users in contextual inquiry resulted in CAPE (CHICAGO Action Plan after ED discharge), a new stakeholder-balanced discharge tool, which is being tested in a multicenter comparative effectiveness trial.

Recruitment, asthma characteristics, and medication behaviors in Midwestern Puerto Rican youth: data from Project CURA.

BACKGROUND Puerto Rican children have the highest prevalence of asthma, but detailed descriptions of this population have been limited to the island of Puerto Rico and the northeastern United States. OBJECTIVE To describe the asthma characteristics of this urban Midwest cohort of Puerto Rican youth, focusing on medication behaviors, and to test whether their asthma outcomes are associated with their demographic and psychosocial variables. METHODS Data are from the baseline cohorts of a randomized controlled trial designed to improve medication adherence in Puerto Rican youth. Recruitment used a community-based participatory research approach. Data were collected in the home. Medications and medication technique were visually assessed, and adherence was determined using electronic medication monitors or counters. Data on asthma symptoms and morbidity, demographics, and psychosocial factors were collected. RESULTS The recruitment of 101 participants (51 in elementary school and 50 in high school) was completed in 14 months. Despite overall high asthma severity and poor asthma control, 20% of participants had no reliever medicine in their home. Self-report of controller use was higher than actual controller medications visualized in the home. For those who had an inhaled corticosteroid medicine (only 45% of elementary school participants and 12% of high school participants), median adherence was 1.0 doses per day. Rates of depression and stress were very high among both caregivers and children. CONCLUSION Puerto Rican youth in the Midwest bear a significant asthma burden in addition to other stressors, including depression. Visual inspection of medications and monitoring of adherence are critical for understanding asthma morbidity in this high-risk population.

Feasibility of percutaneous vagus nerve stimulation for the treatment of acute asthma exacerbations.

OBJECTIVES This study assessed the feasibility of an investigational vagus nerve stimulation (VNS) device for treating acute asthma exacerbations in patients not responding to at least 1 hour of initial standard care therapy. METHODS This was a prospective, nonrandomized study of patients treated in the ED for moderate to severe acute asthma (forced expiratory volume in 1 second [FEV(1)] 25% to 70% of predicted). Treatment entailed percutaneous placement of an electrode near the right carotid sheath and 60 minutes of VNS and continued standard care. VNS voltage was adjusted to perceived improvement, muscle twitching, or adverse events (AEs). All AEs, vital signs, FEV(1), perceived work of breathing (WOB), and final disposition were recorded. RESULTS Twenty-five subjects were enrolled. There were no serious AEs and no significant changes in vital signs. No subject required terminating VNS. One patient had minor bleeding from the procedure, and one had a hematoma and withdrew prior to VNS. AEs related to VNS were temporary and included cough (1 of 24), swallowing difficulty (2 of 24), voice change (2 of 24), and muscle twitching (14 of 24). These resolved when VNS ended. The FEV(1) improved at 15 minutes (median = 15.8%, 95% confidence interval [CI] = 9.3% to 22.4%), 30 minutes (median = 21.3%, 95% CI = 8.1% to 36.5%), and 60 minutes (median = 27.5%, 95% CI = 11.3% to 43.5%). WOB improved at 15 minutes (median = 53.9%, 95% CI = 33.7% to 73.9%), 30 minutes (median = 69.1%, 95% CI = 56.4% to 81.8%), and 60 minutes (median = 81.0%, 95% CI = 68.5% to 93.5%). CONCLUSIONS Percutaneous VNS did not result in serious AEs and was associated with improvements in FEV(1) and perceived dyspnea. Percutaneous VNS appears to be feasible for use in the treatment of moderate to severe acute asthma in patients unresponsive to initial standard care treatment.