Marina Reznik

Perceptions and attitudes of adolescents with asthma.

Background. Psychosocial factors can limit ones ability to effectively manage asthma. This can result in asthma morbidity that limits quality of life. While self-perceptions of asthmatic children and parents have been studied, less is known about self-perceptions of inner-city adolescents with asthma. Objective. To examine perceptions and attitudes to treatment among inner-city adolescents with asthma. Design/Methods. We conducted a multistaged stratified sample survey at a high school located in the Bronx, NY. First, an asthma-screening survey was administered to 3800 registered students. Then, we identified a subset of 200 children with the most positive screening results for asthma. Next, a 32-item self-completion questionnaire was administered to this cohort. Students were surveyed regarding severity of asthma, perceptions and attitudes, and demographic information. Differences in proportions were tested by Chi-square analyses. Pearson rank-order correlation and multiple logistic regression were used to assess the relationship between perceptions and attitudes to self-treatment. Results. A total of 160 (80%) students participated. Mean age was 15.7 years. Of the respondents, 63% were female. 68% were Hispanic, 26% were African American. 33% had weekly symptoms, and 14% had daily symptoms. Additionally, 41% did not know the name of their asthma medicine. Only 38% reported bringing an “asthma pump” when leaving the house. While 70% reported feeling in control over their asthma symptoms, 63% reported feelings of anxiety and 39% could remember a time when they felt like they were going to die from asthma. Subjects who reported feeling in control over their asthma were more likely to take an asthma pump with them when leaving the house (r = 72, p = 0.004). Only 39% had disclosed their asthma to their friends, and 29% felt embarrassed about having an asthma attack in front of their friends. Subjects who felt embarrassed about their asthma were significantly less likely to take their asthma pumps with them (r = 0.98, p<0.001) and less likely to use their medications in front of their friends (r = .87, p<0.001). Conclusions. Adolescents in this study reported feelings of anxiety, fear, and embarrassment about their asthma. Feelings of control over asthma symptoms were associated with positive attitudes toward self-treatment, while embarrassment was correlated with negative attitudes. These findings have implications for counseling adolescents with asthma about self-management strategies.

Predictors of Early Hospital Readmission for Asthma Among Inner-City Children

Factors associated with early asthma readmission have not been fully studied. To identify predictors of early readmission, we performed a matched case-control study of children discharged with primary diagnosis of asthma. Cases were readmitted with asthma within 30 days of discharge. Controls were not readmitted. Conditional logistic regression analysis was used. History of asthma hospitalization within the past 12 months was an independent predictor of early readmission (OR 1.89, p = 0.021). Modifiable factors such as medical treatment and management during and upon discharge from the index admission did not predict early asthma readmission.

In-school asthma management and physical activity: children’s perspectives

Abstract Objective: Regular physical activity (PA) is an important component of pediatric asthma management. No studies have examined how in-school asthma management influences PA from children’s perspectives. The aim of this study was to explore children’s perceptions of the impact of in-school asthma management on PA. Methods: Qualitative interviews with 23 inner-city minority children with asthma (aged 8–10 yrs; 12 girls, 11 boys) were conducted in 10 Bronx, New York elementary schools. Sampling continued until saturation was reached. Interviews were recorded, transcribed and independently coded for common themes. Results: Interviews produced five themes representing students’ perceptions about (1) asthma symptoms during in-school PA; (2) methods to control asthma episodes during school PA; (3) methods to prevent asthma episodes during school; (4) limited accessibility of asthma medications; and (5) negative feelings about asthma and medication use. The majority of students experienced asthma symptoms while performing PA during school. Primary methods of managing asthma symptoms were sitting out during activity, drinking water, and visiting the nurse. Students lacked awareness or adherence to action plans to prevent or control asthma. Students reported limited access to medication during school and feelings of embarrassment and/or concerns of teasing when medicating in front of others. Conclusions: Our results indicate inappropriate in-school management of asthma symptoms, poor asthma control, lack of accessible medication, and stigma around publicly using asthma medication. Thus, students often missed or were withheld from PA. Interventions to improve in-school asthma care must consider ways to address these issues.

Evaluation of MDI-spacer utilization and technique in caregivers of urban minority children with persistent asthma

Abstract Objective: Incorrect Metered-Dose Inhaler (MDI)-spacer technique can result in decreased drug delivery to distal airways and poor asthma outcomes. There is lack of research to examine whether the caregivers utilize proper technique when applying an MDI-spacer delivery system for young minority children with persistent asthma in the United States. The objective of this study was to evaluate MDI-spacer utilization and technique among the caregivers of Bronx minority children with persistent asthma and to determine characteristics associated with correct use. Methods: We analyzed data from 169 caregivers of urban minority children with persistent asthma (aged 2–9 years). MDI-spacer device technique was assessed using a 10-step checklist derived from the national guidelines, literature and manufacturers’ instructions. Based on the median MDI-technique score of six steps demonstrated accurately, caregivers were categorized as correct (seven or more) or incorrect (six or less) users. Results: Of the 169 caregivers, 95% were mothers, mean age 32.3 years (SD 7.6), 56% were unemployed; 74% of the children were Hispanic, 87% had either “not well controlled” or “very poorly controlled” asthma, 92% had a spacer at home and 71% used it “all” or “most” of the time. Only one caregiver correctly demonstrated all 10 steps of the MDI-spacer technique. Child’s having one or more asthma-related hospitalizations in the past 12 months and higher caregiver educational level were independent predictors of correct MDI-spacer technique. Conclusions and relevance: The caregivers of urban, minority children with persistent asthma lack proper MDI-spacer technique, suggesting the potential value of both targeted short- and long-term educational interventions.

Use of interactive videoconferencing to deliver asthma education to inner-city immigrants

Videoconferencing to deliver asthma health education to patients or their parents has not been widely used in the USA. We used two 90 min interactive videoconferences to deliver an asthma education programme to a convenience sample of mainly Latino immigrant parents in the Bronx, New York. In these sessions short presentations were given on asthma triggers, medications and the prevention of asthma exacerbations. To test gains in knowledge, we administered a self-completion questionnaire consisting of true/false statements before and after the videoconferences. Sixty subjects participated in the first videoconference and 56 in the second. Asthma knowledge improved significantly after both. Three months later, knowledge retention from the first videoconference was good. The majority of subjects asked questions and commented on their personal experiences of asthma. Interactive videoconferencing allowed asthma education to be delivered to a large immigrant population, elicited concerns from the audience and was effective in improving knowledge.

Asthma identification and medication administration forms in New York City schools

Asthma is a chronic respiratory disease affecting nearly 9.6% of United States children.1 Asthma disproportionately burdens children from poor and minority backgrounds.2 Children with asthma have high rates of school absenteeism.3 With children spending nearly half of their day at school, appropriate school asthma management can help optimize care for students with asthma. Successful school asthma management involves individual case identification and provision of medications to students when needed.4 New York City (NYC) schools require caregiver submission of a Medication Administration Form (MAF; a physician-completed order form that must be renewed every school year) to confirm asthma diagnoses and allow school nurses to administer medication for asthma exacerbations.5 Without an MAF, due to systems-based regulations, the nurse cannot administer medication, even if a student is having an asthma attack. Many NYC schools struggle with individual asthma case identification6 and have difficulty obtaining MAFs for students, making acute asthma management challenging. Therefore, the objectives of this study were to 1) compare asthma prevalence in four NYC schools based on caregiver and school report; and 2) identify asthma morbidity factors associated with MAF submission. We conducted a cross-sectional survey of caregivers of children attending 2nd-4th grades in four Bronx, New York (NY) elementary schools as the first step in preparation for a school-based intervention study. The NYC Department of Education and the universitys Institutional Review Board (IRB) approved this study. We developed a 6-item self-administered English-Spanish asthma survey based on prior surveys7,8 and NYC DOE guidelines for MAF.5 The survey was field-tested with 10 caregivers of children with and without asthma at routine office visits to ensure questions were clear and easy to comprehend. The survey is available in an online supplement. Surveys and return envelopes were sent home with students during the fall of 2012. Caregivers were instructed to return completed surveys to the classroom teachers in the sealed envelopes. We then collected envelopes from the teachers. Children received a small gift (e.g. stickers, tattoos) for reminding caregivers to return the surveys. Schools were asked to report the number of students with asthma in the same grades. Schools use several Board of Education forms, such as health examination forms and MAFs sent to all students, to identify asthma cases. We performed descriptive statistics for all variables. Differences in proportions were tested by Chi-square. A two-sided α<0.05 was considered statistically significant. We used SPSS V20.0 software (Statistical Product and Service Solutions 20.0, SPSS Inc., Chicago, IL). The survey was distributed to 1,270 students and 769 (61%) were returned. Overall, 192 (25%) children had physician-diagnosed asthma. Of these, 150 (80%) were prescribed asthma medication and 106 (55%) had ≥1 urgent asthma visits in the past year. Half (51%) of caregivers reported that their child had symptoms with exercise and 18 (9%) listed asthma as a condition limiting their childs sports participation. Only 52 (27%) had an MAF at school, and 28 (15%) of caregivers were unaware the MAF existed. (Figure 1) Children were more likely to have an MAF on file at school if they were prescribed asthma medication (32.6% vs 10.5%, p=.007) or had ≥1 urgent asthma visit in the past 12 months (38.7% vs 14.1%, p<.001). Schools identified only 50 students with asthma in the same grades using their usual screening methods. Figure 1 Survey Results on Asthma Identification and Medication Administration Forms in NYC schools. These results show a high prevalence of asthma in this population of inner-city elementary school-age children. According to caregiver report, 1/4 of children had physician-diagnosed asthma. This is consistent with an earlier study that reported a 20% asthma prevalence in several Bronx elementary schools.9 Similarly, the 2009 Child Community Health Survey reported a 16.7% (95% CI (14.4 - 19.4)) asthma prevalence in Bronx children 6-12 years of age.10 Our survey identified many more cases of asthma compared to the prevalence reported by schools. This suggests that methods used by schools to identify children substantially underestimate asthma cases. Further, while children with a medication prescription and those with more urgent visits in the past year were more likely to have an MAF submitted, overall less than 1/3 of caregivers submitted MAF and, even among those with urgent visits, MAFs were frequently unavailable. This makes prompt and appropriate school management of acute asthma challenging and may contribute to avoidable visits to the physicians office or emergency department. Future research should focus on the reasons for low MAF submission by caregivers and the impact system-based regulations may have on students’ school asthma management. Our study had some limitations. The study was conducted in NYC elementary schools. Thus, the conclusions may not be generalizable to other schools in different communities. Our response rate, while comparable to other urban school-based asthma prevalence studies,4 was only 61%. While subject self-selection might have biased estimates of asthma prevalence, an earlier school-based study in the Bronx found similar prevalence rates.9 Differences in the definition of asthma used, methods to identify cases and timing of data collection may have accounted for some discrepancy between asthma cases identified by our survey and those identified by schools. Further, due to privacy rules, we were unable to link individual survey and school data; thus, we do not know if students identified by the school were the same students whose caregivers reported having MAF on file at the school. However these limitations are unlikely to account for the large discrepancy in asthma prevalence found. In conclusion, our study is the first to compare asthma prevalence as reported by caregiver with school report, and to assess factors associated with MAF submission in NYC public schools. We found that a short, take-home, self-administered caregiver survey identified 74% more cases of asthma than schools, and that MAFs are markedly lacking. Instituting a streamlined method of school asthma case identification and communicating to caregivers the importance of MAF may improve school asthma management. Further, this process may serve as the first step toward establishing interventions to improve outcomes of inner-city children with asthma.

The role of telemedicine in the care of children in under-served communities.

Children living in rural and other medically under-served areas are confronted with a shortage of paediatric specialists. Telemedicine has become increasingly popular as a means of providing health education and medical care to people living in rural areas of the United States and other countries. Some US hospitals have had experience with the use of telemedicine to provide subspecialty services to rural children with special health-care needs and health education for immigrant parents. The Medical Missions for Children, a non-profit organization, aims to provide a ‘virtual information bridge’ between sponsoring hospitals in the United States and hospitals located in developing nations. The organization serves children in hospitals in 58 countries throughout Latin America, eastern Europe, South Africa, Nigeria and India, and delivers three to four videoconferences per month. Since its inception, the programme has provided teleconsultations and services to approximately 18,000 children annually. In addition, there are on average 50 educational videoconferences per month, during which physicians at the mentoring hospitals exchange ideas with physicians in the developing countries. About 600 educational videoconferences are conducted annually.

Tuberculin skin testing in children.

Skin testing is recommended for children at risk for this disease.

Do United States’ Teachers Know and Adhere to the National Guidelines on Asthma Management in the Classroom? A Systematic Review

Proper asthma management in schools is important in achieving optimum asthma control in children with asthma. The National Heart, Lung, and Blood Institute (NHLBI) has developed guidelines on classroom asthma management. We conducted a systematic review to examine teacher knowledge of the NHLBI guidelines on asthma management in the classroom. We searched PubMed and EMBASE using search terms “asthma management,” “teacher(s),” “school teacher,” and “public school.” The inclusion criteria were articles published in English from 1994 to May 2014 that focus on schools in the United States (US). From 535 titles and abstracts, 9 studies met inclusion criteria. All studies reported that school teachers did not know the policies and procedures of asthma management. Teachers relied on school nurses to handle medical emergencies. Some studies identified that lack of full-time school nurses was a barrier to asthma management. Only one study showed directly that classroom teachers were not following the NHLBI guidelines on asthma management. Our literature review revealed that US teachers do not know the NHLBI guidelines on asthma management in the classroom. Future research should focus on interventions targeted toward training classroom teachers on asthma management as per NHLBI guidelines to ultimately improve asthma management in schools.

Asthma management in New York City schools: A classroom teacher perspective

Abstract Objective: Classroom teachers play an important role in facilitating asthma management in school but little is known about their perspectives around asthma management. We examined the perspectives of classroom teachers around barriers to school asthma management. Methods: We conducted key informant interviews with 21 inner-city classroom teachers from 3rd to 5th grades in 10 Bronx, New York elementary schools. Sampling continued until thematic saturation was reached. Interviews were recorded, transcribed, and independently coded for common themes. We used thematic and content review to analyze interview data. Results: Seven themes representing teachers’ perspectives on in-school asthma management emerged: (1) the problematic process of identifying students with asthma; (2) poor familiarity with the city health departments asthma initiative and poor general knowledge of school policies on asthma management; (3) lack of competency in managing an acute asthma attack in the classroom and poor recognition of symptoms of an asthma attack; (4) lack of confidence in dealing with a hypothetical asthma attack in the classroom; (5) lack of quick access to asthma medication in school; (6) limited communication between school staff; and (7) enthusiasm about learning more about asthma management. Conclusions: Our results revealed several barriers contributing to suboptimal in-school asthma management: ineffective ways of identifying students with asthma, lack of teacher knowledge of guidelines on asthma management, lack of comfort in managing students’ asthma, inadequate access to asthma medication in school, and limited communication between school staff. These issues should be considered in the design of interventions to improve in-school asthma management.