554500
research-article2014
CPJXXX10.1177/0009922814554500Clinical PediatricsFriend and Morrison
Original Article
Interventions to Improve Asthma Management of the School-Age Child
Clinical Pediatrics 1–9 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814554500 cpj.sagepub.com
Mary Friend, BSN, RN, CPN1, and Amber Morrison, BSN, RN1
Abstract Improvement of medication adherence in the school-age child can lead to improvement in quality of life, decreased morbidity, and a potential decreased risk of deferred academic, social, and emotional development. The objective of this article is to review barriers to asthma medication adherence and identify evidence-based techniques that improve medication management of the asthmatic child 5 to 12 years of age. A literature review was performed and articles were obtained through database searches within Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed. Research indicates that barriers to the adherence of medication regimens required for asthmatic children include poor understanding of the medication regimen, substandard education on symptom recognition and environmental triggers, rejection of the diagnosis, and a lack of support or understanding within the community. Researched techniques aimed to improve medication management in 5- to 12-year-olds include: computer-based education; workshops for parents, teachers, and children; incorporation of asthma education into classroom lessons; use of case managers; the introduction of a nurse practitioner in the school to provide care, including medication prescriptions for the asthmatic child; and assessment and evaluation of environmental and emotional triggers in the home and school. Collaboration of current data may help lead to a successful interventional model that can improve asthma management in this population. Keywords asthma, children, pediatric, education, perceptions, adherence, management, compliance, barriers Asthma is a health concern that affects 7 to 9 million children in the United States, making it one of the most common childhood illnesses in the United States.1,2 The prevalence of children with asthma has been on the rise in the United States over the past few decades.1 The National Asthma Education and Prevention Program (NAEPP) provides guidelines to improve the care of asthma, which included: patient education, incorporation of a written asthma action plan, and education about symptom assessment and environmental factors that contribute to asthma severity.3 However, statistics show poor practitioner compliance of these guidelines. Only 34.2% of asthmatics (and/or their caregivers) report receiving a written asthma action plan, only 49.3% report advisement on environmental triggers, and only about 60% report education of symptom recognition.3 While proper education is an important aspect of asthmatic care, it is only one focal point in the entirety of asthma management. A diagnosis of asthma puts a child at increased risk of deprived school readiness, reduced academic performance in school, more school absences, and starting school behind their peers.4 Additionally, many internal
and external factors affecting the child, caregiver, and community can contribute to poor medication adherence and asthma management.1,4 For example, increased disease severity can be observed among depressed children, particularly those living within an emotionally turbulent family climate.5 However, interventions that engage the family, peers, health system, and schools have proven to alleviate these extrinsic factors that affect asthma management.6 Evidence illustrates that improvement of medication adherence and asthma management in the school-age child can lead to improvement in quality of life and better utilization of medical services. By employing these evidence-based interventions in the management of asthma, the morbidity and mortality of asthmatic children will decrease.
1
University of Cincinnati, Cincinnati, OH, USA
Corresponding Author: Mary Friend, 5790 Biscayne Avenue, Cincinnati, OH 45248, USA. Email: [email protected]
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Clinical Pediatrics
Purpose This review evaluates barriers to asthma medication and management adherence, as well as identifies current techniques targeted at improving medication management in 5- to 12-year-old asthmatic children. The aim is to provide evidence-based recommendations to implement within the outpatient setting to improve asthma management in school-age children. Though there is research present on this subject, there is no specific evidence-based technique or intervention that can be implemented by providers to improve asthma management in school-age children. Reviewing current data and drawing new conclusions will, ideally, lead to a successful interventional technique that will improve asthma management in this population.
Methods A literature review was completed on publications concerning asthmatic children aged 5 to 12 years, with the aim to assess barriers in asthma management and asthmatic medication use. Research-based information was gathered on interventions intended to improve asthma management and medication adherence in these school-age asthmatics. Articles reviewed were obtained through database searches within Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed by 2 researchers in the autumn and winter months of 2013 to winter 2014. Search terms used included combinations of the following: asthma, children, pediatric, school-age, education, perceptions, adherence, management, barriers, and compliance. Results were restricted to (1) articles published between the years of 2006 and 2014, (2) articles that included research on school-based interventions to improve asthma control in elementary schools, and (3) research on barriers to proper management of asthma in 5- to 12-year-olds. The articles chosen have a high representation of lower socioeconomic status families. Research articles chosen use primarily an inductive reasoning approach, are a primary source of research, and are sources of knowledge from experimentation, participant observation, document examination, and interviewing. Literature review articles were used in moderation and restricted to those with authors that have knowledge, qualifications, or positions in this field. Research not published in English and not available through electronic libraries was excluded. Gathered research was analyzed to develop an interventional technique that can be implemented within the outpatient
setting to improve medication adherence and management in asthmatic school-age children.
State of Literature Barriers Research indicates that multiple barriers to asthma management exist. A common finding among publications is the lack of understanding of medication regimen, as related to the lack of education for the family, community, and school personnel.7,8 Poor continuity of care or lack of a primary care provider (PCP)9,10 and lack of asthma diagnosis by the child’s PCP11,12 are also noted obstacles. Bender and Zhang13 shows patients and parents with anxiety or depression have substandard asthma management, as manifested by school absences secondary to asthma and symptoms of asthma. Other barriers include lack of parental support,11,14 insufficient school support, and lack of knowledge or inability to control environmental triggers.11,12
Addressing Education There have been multiple teaching techniques successfully implemented that improve medication management among 5- to 12-year-olds though educating the child, parents, peers, and school personnel. These techniques include: computer-based education6,15; after school workshops for parents, teachers and children16,17; and incorporation of asthma education into classroom lessons.18 In addition, Lack7 expands on these interventions by implementing computer education and scheduling follow-up appoints before leaving an emergency department, in attempt to improve asthma knowledge and increase the likelihood of follow-up.
Emotional Factors Several studies investigate the emotional components of the disease, such as the child’s overall feelings about the disease, the parent’s emotional disposition, and the community attitudes about the disease. Dellen et al19 recognizes that children positively stimulated by their parents to use inhaled corticosteroid as prescribed have a better asthma medication adherence; likewise, better adherence is found in families with a positive attitude about the medication. Mandhane et al20 assesses the child and caregiver perceptions of asthma, along with the child’s quality of life, in aim to determine how these relate to asthma management. Results show that while the child’s quality of life perception did not correlate with their
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Friend and Morrison caregiver’s perceptions, the caregiver’s perceptions did influence the child’s asthma management.20 Celano et al21 performed a pilot study indicating that implementation of home-based interventions addressing psychosocial needs could prevent asthma related hospitalizations. McMullen et al8 noted that providers often fail to inquire about the child’s feelings, worries about the disease, and/or concerns regarding ability to manage asthma exacerbations. Failure to acknowledge such issues can result in decreased adherence to asthma management plans.
School and Provider Support Strong evidence suggests incorporating a case manager and/or a nurse practitioner within the school environment can significantly improve school attendance and decrease morbidity. Levy et al22 obtained such outcomes by introducing a nurse case manager into high risk schools that provided weekly coaching, teaching, and monitoring of asthmatic students; coordination of care among the students, family members, school personnel, and medical providers; and education to school principals and staff. These measures correlated with fewer school absences, emergent care visits, and hospitalizations, as well as improved asthma knowledge among parents and the asthmatic child.22 Another approach, posited by Toole,23 utilizes the school nurse to identify students that have poor symptom control or who show symptoms without a proper diagnosis. After identifying these students, a nurse practitioner follows up by performing an in-school asthma evaluation to assess the child’s symptoms, develop a written asthma action plan, and prescribe controller medications as indicated.23
Clinical Practice Implications While education is the focal point of several research efforts, results from the literature review seem to suggest that interventions that are multidimensional have more efficacy in proper disease management. In addition to reiteration and review of the asthmatic medication regimen, increased access to care through the implementation of nurse practioners or case managers within schools can aid in asthma management. Factors including patient affect, social influences, and available resources should also be addressed when implementing an asthma management plan in school-age children. Considering all these factors are important when determining interventions for improving disease management among school age asthmatics.
Models of Asthma Management A proper interventional tool for outpatient providers will allow more thorough management and follow-up during treatment of school-age asthmatics. According to Bonfenbrenner’s24 bioecological systems theory and current research, illness management and morbidity fluctuate depending on the risk factors in the patient’s social and biological life. By applying a proper interventional tool based on Bonfenbrenner’s socioecological theory, the provider can apply a systematic assessment of the child’s environment to identify the factors that foster or hinder asthma management. Implementation of such a tool will provide a consistent guide for the PCP to use at initiation of treatment and at follow-up visits. This tool will address the bidirectional influences between the environment and the child’s asthma management. The concept from the social ecological model of asthma management presented by Narr-King et al25 is based on this theory. Naar-King et al’s25 adaptation of Bronfenbrenner’s model includes the many layers that affect asthma management including: community, peers and society, family, and the child. Figure 1 demonstrates Naar-King et al’s application of this theory. While this adaptation was developed with the psychiatry aspect of medicine in mind, it can also be adapted for use by PCP to improve asthma management in the school-age child. This model recognizes the many aspects of the child that affect the PCP’s plan of care for the asthmatic child.
Suggested Interventional Tool Based on Presented Research The first challenge in the management of asthmatic children is initiating a proper diagnosis, which can be made by a PCP or by collaboration between the school nurse and a nurse practitioner as posited by Toole.23 Liberatos et al14 found that approximately 13% of children had asthma symptoms without a diagnosis of asthma, suggesting that providers are reluctant to “label” a child with an asthma diagnosis. Once a diagnosis is confirmed, the provider can move forward with a comprehensive management plan. After diagnosis, the patient and caregiver should receive proper education that complies with National Asthma Education and Prevention Program guidelines found on the National Institute of Health’s Web site. An Asthma Care Quick Reference desk pamphlet is available for providers, with the purpose of providing information to diagnose, treat, monitor, and adjust therapy as needed. At the time of diagnosis, providers should begin
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Clinical Pediatrics
Figure 1. Social ecological model of asthma management.25
to assess the psychological components of the child and caregiver. Factors such as their acceptance and perception of diagnosis are important to assess at each visit. An effective assessment tool could be a previsit questionnaire, which gives providers a measurable analysis of each component. Figures 2 and 3 show examples of questionnaire tools. If not already in contact with the school, the provider should request parental permission to contact the school and provide the school with a copy of the child’s asthma action plan. It is up to the provider to implement the 2-page asthma action plan, making sure to emphasize that asthma triggers can be easily reviewed on the second page. A final comprehensive plan would also include education beyond the patient and caregiver, such as involvement with school staff, case managers, psychology services and other community services. Providers assist to ensure that school faculty is educated in the recognition of symptoms and proper management through educational pamphlets, after-school workshops or in-service presentations. Incorporating
asthma education into classroom lessons, as suggested in Pike et al,18 can aid peer understanding in the disease, in turn, alleviating some of the social pressures placed on the child.
Conclusion Current statistics show that proper asthma management and medication adherence extends beyond the patient and provider appointments. Research has shown that education-based programs alone do not improve asthma morbidity in school-age children. Guidelines provided by the National Institute of Health allow providers to remain consistent in proper diagnosis and medication use. Utilizing assessment tools such as questionnaires to measure other intangible components contribute to a more comprehensive assessment of patient needs. It is only by addressing the many layers of the child’s being, that providers and the community can enhance the asthmatic child’s quality of life and continue to improve asthma management in school age children.
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Friend and Morrison Original Article
My Child’s Asthma Management Questionnaire
Note: Your health care provider will review this questionnaire and address areas of concern to enhance care of your child’s asthma. Asthma Management: 1. Do you have trouble understanding your child’s Asthma medications or Asthma Action Plan? 2. Do you have any questions about your child’s Asthma medications, Asthma Action Plan, or Asthma Control? Environment & Triggers: 1. Do you know what the asthma triggers are for your child?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
If yes, please list asthma triggers for your child:
2. Do you feel like you have the financial means to help your child avoid asthma triggers? If no, please explain:
3. Are there any pets in the home that are an asthma triggers for your child? If yes, do they enter your child’s room?
YES NO
4. Look at the second page of your Asthma Action Plan. Are there any asthma triggers in your home that you feel like your child is unable to avoid? If yes, please explain:
YES
NO
YES
NO
2. Do you feel your current health care provider can assist you better in managing your child’s asthma?
YES
NO
3. Do you have difficulty communicating your concerns to your child’s healthcare provider?
YES
NO
4. Do you believe your child does not need the prescribed medications to control his/her asthma and to avoid asthma exacerbations?
YES
NO
5. Do you ever fear giving your child his/her asthma medications?
YES
NO
5. Is everyone that your child lives with tobacco free indoors and outdoors? Health Beliefs and Asthma: 1. Do you believe that your child has been properly diagnosed with asthma?
(continued)
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Clinical Pediatrics
Figure 2. (continued) Friend and Morrison
5
If yes, please list your concerns:
6. Do you ever decide not give your child his/her asthma medications as prescribed?
YES
NO
If yes, please explain these situations:
7. Do you feel your child’s Asthma Action Plan or medications do more harm than good?
YES
NO
YES
NO
YES
NO
2. Do you feel your child’s friends are supportive of your child’s asthma management?
YES
NO
3. Do you feel your family is supportive of your child’s asthma management?
YES
NO
4. Do you feel that others exclude your child because your child has asthma?
YES
NO
5. Do you feel like your social activities are limited because your child has asthma?
YES
NO
6. Do you feel like your child gets emotional or stressed due to his/her asthma?
YES
NO
YES
NO
If yes, please provide your concerns:
8. Do you feel like there is a better way to manage your child’s asthma?
If yes, please share your thoughts/ideas:
Psychosocial and Asthma: 1. Do you feel your child’s school can provide support for your child’s asthma?
Community and Asthma: 1. Do you feel like there are things in your community, neighborhood, or home that negatively contribute to your child’s asthma? If yes, please circle or list your concerns: Poor air quality Social Support Neighborhood Cleanliness
Access to Healthcare Living Expenses Work Smoking Prevalence Old/Poor Housing Stress Other (please list)
Figure 2. “Asthma follow-up packet” for parent.
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Friend and Morrison Original Article Provider Assessment: The Patient’s Asthma Knowledge Rate the patient’s ability to complete/answer each of the following items: 1. Can you explain to me how your Asthma Action Plan works? -Patient: has full understanding (great), knows some yet needs some assistance (good), does not know/needs a lot of assistance understanding (needs work) 2. Which medicine is your rescue inhaler? Which medicine is your daily/maintenance inhaler?
Great
Good
Needs Work
Great
Good
Needs Work
Great
Good
Needs Work
Great
Good
Needs Work
Great
Good
Needs Work
-Patient: knows both (great), knows one (good), doesn’t know either (needs work) 3. Can you show me how you take your medicine for your asthma? -Patient: demonstrates all steps properly (great), knows basic steps yet still requires reminders on other steps (good), does not demonstrate appropriately (needs work) 4. What are triggers that cause your asthma to get worse? -Patient: identifies his/her triggers (great), knows some triggers, but not all (good), does not know triggers (needs work) 5. What do you feel like when you need your rescue inhaler? -Patient: identifies at least 3 symptoms (great), 1-2 symptoms (good), 0 symptoms (needs work. 6. Does having asthma mean that you cannot exercise or play? -Patient: understands need to have rescue inhaler readily available and to monitor for symptoms (great), believes that activities are limited even when not having an exacerbation, yet knows triggers and use of rescue inhaler (good), believes that activities are limited and does know triggers and/or rescue inhaler (needs work)
Great Good
Needs Work
All of the items that “Needs Work” can be addressed by education of the patients Asthma Action Plan and proper use of medication.
The items on this assessment page that are labeled “Needs Work” are being addressed during this visit by:
Demonstration followed by return demonstration by the patient
Handouts followed by verbalized understanding from the patient
Verbal Education given by the provider followed by verbalized understanding from the patient
Provider: ______________________________
Date:________________
(continued)
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Clinical Pediatrics
Figure 3. (continued) Friend and Morrison
7
Child Health Belief & Psychosocial Questionnaire Do you feel as confident about yourself as you did when you did not have asthma? If no, how do you feel different now that you have asthma?
YES
NO
YES
NO
YES
NO
Do you feel like your friends will help you with your asthma if you need it?
YES
NO
Does your school staff (teachers, school nurse, principal) know you have asthma?
YES
NO
Do you feel like your school staff will help you with your asthma if you need it?
YES
NO
Are you able to treat your asthma while you are away from your parent(s), even if it gets worse?
YES
NO
Do you feel like your parents or family will help you with your asthma if you need it? Do your friends know you have asthma? If yes, do your friends treat you the same, now that they know you have asthma?
On a scale of 0 to 10, how confident are you in handing your asthma while you are away from your parent? 0 = not confident (cannot treat your asthma on your own) 10 = very confident (you do not need any assistance to treat your asthma when parent is not around), 0
1
2
3
4
5
6
7
8
9
10
Figure 3. “Asthma follow-up packet” for child.
Acknowledgments
Declaration of Conflicting Interests
The authors thank Dr Ronald L. Tyson, DNP, DMin, CNP, PMHNP-BC, ANP-BC; FNP Distant Learning Program College of Nursing, University of Cincinnati.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Friend and Morrison Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Moorman JE, Akinbami LJ, Bailey CM, et al. National surveillance of asthma: United States, 2001-2010. Vital Health Stat 3. 2012;(35):1-67. 2. Lim J, Wood B, Cheah P. Understanding children with asthma: trouble and triggers. Child Educ. 2009;85:307312. doi:10.1080/00094056.2009.10521704. 3. Centers for Disease Control and Prevention. Vital signs: asthma prevalence, disease characteristics, and selfmanagement education: United States, 2001-2009. MMWR Morb Mortal Wkly Rep. 2011;60:547-552. 4. Davis DW, Gordon MK, Burns BM. Educational interventions for childhood asthma: a review and integrative model for preschoolers from low-income families. Pediatr Nurs. 2011;37:31-38. 5. Wood BL, Lim J, Miller BD, et al. Testing the Biobehavioral Family Model in pediatric asthma: pathways of effect. Fam Process. 2008;47:21-40. doi:10.1111/ j.1545-5300.2008.00237.x. 6. Wyatt T, Hauenstein E. Pilot testing Okay With Asthma: an online asthma intervention for school-age children. J Sch Nurs. 2008;24:145-150. doi:10.1622/10598405(2008)024[0145:PTOWAA]2.0.CO;2. 7. Lack S. Education of the pediatric patient with asthma: A literature review. J Pediatr Nurs. 2008;27:174-176. doi:10.1016/j.pedn.2011.12.005. 8. McMullen A, Yoos HL, Anson E, Kitzmann H, Halterman JS, Arcoleo KS. Asthma care of children in clinical practice: do parents report receiving appropriate education? Pediatr Nurs. 2007;33:37-44. 9. Seid M, Opipari-Arrigan L, Gelhard LR, Varni JW, Driscoll K. Barriers to care questionnaire: reliability, validity, and responsiveness to change among parents of children with asthma. Acad Pediatr. 2009;9:106-113. doi:10.1016/j.acap.2008.12.003. 10. Valerio M, Cabana MD, White DF, Heidmann DM, Brown RW, Bratton SL. Understanding of asthma management: Medicaid parents’ perspectives. Chest. 2006;129:594601. doi:10.1378/chest.129.3.594. 11. Forbis S, Rammel J, Huffman B, Taylor R. Barriers to care of inner-city children with asthma: school nurse perspective. J Sch Health, 2006;76:205-207. doi:10.1111/ j.1746-1561.2006.00097.x. 12. Laster N, Holsey CN, Shendell DG, Mccarty FA, Celano M. Barriers to asthma management among urban families: caregiver and child perspectives. J Asthma. 2009;46:731739. doi:10.1080/02770900903082571.
13. Bender B, Zhang L. Negative affect, medication adherence, and asthma control in children. J Allergy Clin Immunol. 2008;122:490-495. doi:10.1016/j.jaci.2008.05.041. 14. Liberatos P, Leone J, Craig AM, Frei EM, Fuentes N, Harris IM. Challenges of asthma management for school nurses in districts with high asthma hospitalization rates. J Sch Health. 2013;83:867-875. doi:10.1111/josh.12105. 15. Nabors LA, Kockritz JL, Ludke RL, Bernstein JA. Enhancing school-based asthma education efforts using computer-based education for children. J Asthma. 2012;49:209-212. doi:10.3109/02770903.2011.645181. 16. DePue JD, McQuaid EL, Koinis-Mitchell D, Camillo C, Alario A, Klein RB. Providence school asthma partnership: schoolbased asthma program for inner-city families. J Asthma. 2007;44:449-453. doi:10.1080/027-70900701421955. 17. Gerald LB, Redden D, Wittich AR, et al. Outcomes for a comprehensive school-based asthma management program. J Sch Health. 2006;76:291-296. doi:10.1111/ j.1746-1561.2006.00114.x. 18. Pike EV, Richmond CM, Hobson A, Kleiss J, Wottowa J, Sterling DA. Development and evaluation of an integrated asthma awareness curriculum for the elementary school classroom. J Urban Health. 2011;88(suppl 1):S61-S67. doi:10.1007/s11524-010-9477-x. 19. van Dellen QM, Stronks K, Bindels PJ, Ory FG, van Aalderen WM, PEACE Study Group. Adherence to inhaled corticosteroids in children with asthma and their parents. Respir Med. 2008;102:755-763. doi:10.1016/j.rmed.2007.12.005. 20. Mandhane PJ, McGhan SL, Sharpe HM, et al. A child’s asthma quality of life rating does not significantly influence management of their asthma. Pediatr Pulmonol. 2010;45:141-148. doi:10.1002/ppul.21157. 21. Celano MP, Holsey CN, Kobrynski LJ. Home-based family intervention for low-income children with asthma: a randomized controlled pilot study. J Fam Psychol. 2012;26:171-178. doi:10.1037/a0027218. 22. Levy M, Heffner B, Stewart T, Beeman G. The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. J Sch Health. 2006;76:320-324. doi:10.1111/j.17461561.2006.00120.x. 23. Toole KP. Helping children gain asthma control: bundled school-based interventions. Pediatr Nurs. 2013;39:115-124. 24. Bronfenbrenner U. Toward an experimental ecology of human development. Am Psychol. 1977;32:513-531. doi:10.1037/0003-066X.32.7.513. 25. Naar-King S, Ellis D, Kolmodin K, Cunningham P, Secord E. Feasibility of adapting multisystemic therapy to improve illness management behaviors and reduce asthma morbidity in high-risk African American youth: a case series. J Child Fam Stud. 2009;18:564-573. doi:10.1007/ s10826-009-9259-9.
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research-article2014
CPJXXX10.1177/0009922814554500Clinical PediatricsFriend and Morrison
Original Article
Interventions to Improve Asthma Management of the School-Age Child
Clinical Pediatrics 1–9 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814554500 cpj.sagepub.com
Mary Friend, BSN, RN, CPN1, and Amber Morrison, BSN, RN1
Abstract Improvement of medication adherence in the school-age child can lead to improvement in quality of life, decreased morbidity, and a potential decreased risk of deferred academic, social, and emotional development. The objective of this article is to review barriers to asthma medication adherence and identify evidence-based techniques that improve medication management of the asthmatic child 5 to 12 years of age. A literature review was performed and articles were obtained through database searches within Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed. Research indicates that barriers to the adherence of medication regimens required for asthmatic children include poor understanding of the medication regimen, substandard education on symptom recognition and environmental triggers, rejection of the diagnosis, and a lack of support or understanding within the community. Researched techniques aimed to improve medication management in 5- to 12-year-olds include: computer-based education; workshops for parents, teachers, and children; incorporation of asthma education into classroom lessons; use of case managers; the introduction of a nurse practitioner in the school to provide care, including medication prescriptions for the asthmatic child; and assessment and evaluation of environmental and emotional triggers in the home and school. Collaboration of current data may help lead to a successful interventional model that can improve asthma management in this population. Keywords asthma, children, pediatric, education, perceptions, adherence, management, compliance, barriers Asthma is a health concern that affects 7 to 9 million children in the United States, making it one of the most common childhood illnesses in the United States.1,2 The prevalence of children with asthma has been on the rise in the United States over the past few decades.1 The National Asthma Education and Prevention Program (NAEPP) provides guidelines to improve the care of asthma, which included: patient education, incorporation of a written asthma action plan, and education about symptom assessment and environmental factors that contribute to asthma severity.3 However, statistics show poor practitioner compliance of these guidelines. Only 34.2% of asthmatics (and/or their caregivers) report receiving a written asthma action plan, only 49.3% report advisement on environmental triggers, and only about 60% report education of symptom recognition.3 While proper education is an important aspect of asthmatic care, it is only one focal point in the entirety of asthma management. A diagnosis of asthma puts a child at increased risk of deprived school readiness, reduced academic performance in school, more school absences, and starting school behind their peers.4 Additionally, many internal
and external factors affecting the child, caregiver, and community can contribute to poor medication adherence and asthma management.1,4 For example, increased disease severity can be observed among depressed children, particularly those living within an emotionally turbulent family climate.5 However, interventions that engage the family, peers, health system, and schools have proven to alleviate these extrinsic factors that affect asthma management.6 Evidence illustrates that improvement of medication adherence and asthma management in the school-age child can lead to improvement in quality of life and better utilization of medical services. By employing these evidence-based interventions in the management of asthma, the morbidity and mortality of asthmatic children will decrease.
1
University of Cincinnati, Cincinnati, OH, USA
Corresponding Author: Mary Friend, 5790 Biscayne Avenue, Cincinnati, OH 45248, USA. Email: [email protected]
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2
Clinical Pediatrics
Purpose This review evaluates barriers to asthma medication and management adherence, as well as identifies current techniques targeted at improving medication management in 5- to 12-year-old asthmatic children. The aim is to provide evidence-based recommendations to implement within the outpatient setting to improve asthma management in school-age children. Though there is research present on this subject, there is no specific evidence-based technique or intervention that can be implemented by providers to improve asthma management in school-age children. Reviewing current data and drawing new conclusions will, ideally, lead to a successful interventional technique that will improve asthma management in this population.
Methods A literature review was completed on publications concerning asthmatic children aged 5 to 12 years, with the aim to assess barriers in asthma management and asthmatic medication use. Research-based information was gathered on interventions intended to improve asthma management and medication adherence in these school-age asthmatics. Articles reviewed were obtained through database searches within Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed by 2 researchers in the autumn and winter months of 2013 to winter 2014. Search terms used included combinations of the following: asthma, children, pediatric, school-age, education, perceptions, adherence, management, barriers, and compliance. Results were restricted to (1) articles published between the years of 2006 and 2014, (2) articles that included research on school-based interventions to improve asthma control in elementary schools, and (3) research on barriers to proper management of asthma in 5- to 12-year-olds. The articles chosen have a high representation of lower socioeconomic status families. Research articles chosen use primarily an inductive reasoning approach, are a primary source of research, and are sources of knowledge from experimentation, participant observation, document examination, and interviewing. Literature review articles were used in moderation and restricted to those with authors that have knowledge, qualifications, or positions in this field. Research not published in English and not available through electronic libraries was excluded. Gathered research was analyzed to develop an interventional technique that can be implemented within the outpatient
setting to improve medication adherence and management in asthmatic school-age children.
State of Literature Barriers Research indicates that multiple barriers to asthma management exist. A common finding among publications is the lack of understanding of medication regimen, as related to the lack of education for the family, community, and school personnel.7,8 Poor continuity of care or lack of a primary care provider (PCP)9,10 and lack of asthma diagnosis by the child’s PCP11,12 are also noted obstacles. Bender and Zhang13 shows patients and parents with anxiety or depression have substandard asthma management, as manifested by school absences secondary to asthma and symptoms of asthma. Other barriers include lack of parental support,11,14 insufficient school support, and lack of knowledge or inability to control environmental triggers.11,12
Addressing Education There have been multiple teaching techniques successfully implemented that improve medication management among 5- to 12-year-olds though educating the child, parents, peers, and school personnel. These techniques include: computer-based education6,15; after school workshops for parents, teachers and children16,17; and incorporation of asthma education into classroom lessons.18 In addition, Lack7 expands on these interventions by implementing computer education and scheduling follow-up appoints before leaving an emergency department, in attempt to improve asthma knowledge and increase the likelihood of follow-up.
Emotional Factors Several studies investigate the emotional components of the disease, such as the child’s overall feelings about the disease, the parent’s emotional disposition, and the community attitudes about the disease. Dellen et al19 recognizes that children positively stimulated by their parents to use inhaled corticosteroid as prescribed have a better asthma medication adherence; likewise, better adherence is found in families with a positive attitude about the medication. Mandhane et al20 assesses the child and caregiver perceptions of asthma, along with the child’s quality of life, in aim to determine how these relate to asthma management. Results show that while the child’s quality of life perception did not correlate with their
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Friend and Morrison caregiver’s perceptions, the caregiver’s perceptions did influence the child’s asthma management.20 Celano et al21 performed a pilot study indicating that implementation of home-based interventions addressing psychosocial needs could prevent asthma related hospitalizations. McMullen et al8 noted that providers often fail to inquire about the child’s feelings, worries about the disease, and/or concerns regarding ability to manage asthma exacerbations. Failure to acknowledge such issues can result in decreased adherence to asthma management plans.
School and Provider Support Strong evidence suggests incorporating a case manager and/or a nurse practitioner within the school environment can significantly improve school attendance and decrease morbidity. Levy et al22 obtained such outcomes by introducing a nurse case manager into high risk schools that provided weekly coaching, teaching, and monitoring of asthmatic students; coordination of care among the students, family members, school personnel, and medical providers; and education to school principals and staff. These measures correlated with fewer school absences, emergent care visits, and hospitalizations, as well as improved asthma knowledge among parents and the asthmatic child.22 Another approach, posited by Toole,23 utilizes the school nurse to identify students that have poor symptom control or who show symptoms without a proper diagnosis. After identifying these students, a nurse practitioner follows up by performing an in-school asthma evaluation to assess the child’s symptoms, develop a written asthma action plan, and prescribe controller medications as indicated.23
Clinical Practice Implications While education is the focal point of several research efforts, results from the literature review seem to suggest that interventions that are multidimensional have more efficacy in proper disease management. In addition to reiteration and review of the asthmatic medication regimen, increased access to care through the implementation of nurse practioners or case managers within schools can aid in asthma management. Factors including patient affect, social influences, and available resources should also be addressed when implementing an asthma management plan in school-age children. Considering all these factors are important when determining interventions for improving disease management among school age asthmatics.
Models of Asthma Management A proper interventional tool for outpatient providers will allow more thorough management and follow-up during treatment of school-age asthmatics. According to Bonfenbrenner’s24 bioecological systems theory and current research, illness management and morbidity fluctuate depending on the risk factors in the patient’s social and biological life. By applying a proper interventional tool based on Bonfenbrenner’s socioecological theory, the provider can apply a systematic assessment of the child’s environment to identify the factors that foster or hinder asthma management. Implementation of such a tool will provide a consistent guide for the PCP to use at initiation of treatment and at follow-up visits. This tool will address the bidirectional influences between the environment and the child’s asthma management. The concept from the social ecological model of asthma management presented by Narr-King et al25 is based on this theory. Naar-King et al’s25 adaptation of Bronfenbrenner’s model includes the many layers that affect asthma management including: community, peers and society, family, and the child. Figure 1 demonstrates Naar-King et al’s application of this theory. While this adaptation was developed with the psychiatry aspect of medicine in mind, it can also be adapted for use by PCP to improve asthma management in the school-age child. This model recognizes the many aspects of the child that affect the PCP’s plan of care for the asthmatic child.
Suggested Interventional Tool Based on Presented Research The first challenge in the management of asthmatic children is initiating a proper diagnosis, which can be made by a PCP or by collaboration between the school nurse and a nurse practitioner as posited by Toole.23 Liberatos et al14 found that approximately 13% of children had asthma symptoms without a diagnosis of asthma, suggesting that providers are reluctant to “label” a child with an asthma diagnosis. Once a diagnosis is confirmed, the provider can move forward with a comprehensive management plan. After diagnosis, the patient and caregiver should receive proper education that complies with National Asthma Education and Prevention Program guidelines found on the National Institute of Health’s Web site. An Asthma Care Quick Reference desk pamphlet is available for providers, with the purpose of providing information to diagnose, treat, monitor, and adjust therapy as needed. At the time of diagnosis, providers should begin
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Clinical Pediatrics
Figure 1. Social ecological model of asthma management.25
to assess the psychological components of the child and caregiver. Factors such as their acceptance and perception of diagnosis are important to assess at each visit. An effective assessment tool could be a previsit questionnaire, which gives providers a measurable analysis of each component. Figures 2 and 3 show examples of questionnaire tools. If not already in contact with the school, the provider should request parental permission to contact the school and provide the school with a copy of the child’s asthma action plan. It is up to the provider to implement the 2-page asthma action plan, making sure to emphasize that asthma triggers can be easily reviewed on the second page. A final comprehensive plan would also include education beyond the patient and caregiver, such as involvement with school staff, case managers, psychology services and other community services. Providers assist to ensure that school faculty is educated in the recognition of symptoms and proper management through educational pamphlets, after-school workshops or in-service presentations. Incorporating
asthma education into classroom lessons, as suggested in Pike et al,18 can aid peer understanding in the disease, in turn, alleviating some of the social pressures placed on the child.
Conclusion Current statistics show that proper asthma management and medication adherence extends beyond the patient and provider appointments. Research has shown that education-based programs alone do not improve asthma morbidity in school-age children. Guidelines provided by the National Institute of Health allow providers to remain consistent in proper diagnosis and medication use. Utilizing assessment tools such as questionnaires to measure other intangible components contribute to a more comprehensive assessment of patient needs. It is only by addressing the many layers of the child’s being, that providers and the community can enhance the asthmatic child’s quality of life and continue to improve asthma management in school age children.
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Friend and Morrison Original Article
My Child’s Asthma Management Questionnaire
Note: Your health care provider will review this questionnaire and address areas of concern to enhance care of your child’s asthma. Asthma Management: 1. Do you have trouble understanding your child’s Asthma medications or Asthma Action Plan? 2. Do you have any questions about your child’s Asthma medications, Asthma Action Plan, or Asthma Control? Environment & Triggers: 1. Do you know what the asthma triggers are for your child?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
If yes, please list asthma triggers for your child:
2. Do you feel like you have the financial means to help your child avoid asthma triggers? If no, please explain:
3. Are there any pets in the home that are an asthma triggers for your child? If yes, do they enter your child’s room?
YES NO
4. Look at the second page of your Asthma Action Plan. Are there any asthma triggers in your home that you feel like your child is unable to avoid? If yes, please explain:
YES
NO
YES
NO
2. Do you feel your current health care provider can assist you better in managing your child’s asthma?
YES
NO
3. Do you have difficulty communicating your concerns to your child’s healthcare provider?
YES
NO
4. Do you believe your child does not need the prescribed medications to control his/her asthma and to avoid asthma exacerbations?
YES
NO
5. Do you ever fear giving your child his/her asthma medications?
YES
NO
5. Is everyone that your child lives with tobacco free indoors and outdoors? Health Beliefs and Asthma: 1. Do you believe that your child has been properly diagnosed with asthma?
(continued)
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Clinical Pediatrics
Figure 2. (continued) Friend and Morrison
5
If yes, please list your concerns:
6. Do you ever decide not give your child his/her asthma medications as prescribed?
YES
NO
If yes, please explain these situations:
7. Do you feel your child’s Asthma Action Plan or medications do more harm than good?
YES
NO
YES
NO
YES
NO
2. Do you feel your child’s friends are supportive of your child’s asthma management?
YES
NO
3. Do you feel your family is supportive of your child’s asthma management?
YES
NO
4. Do you feel that others exclude your child because your child has asthma?
YES
NO
5. Do you feel like your social activities are limited because your child has asthma?
YES
NO
6. Do you feel like your child gets emotional or stressed due to his/her asthma?
YES
NO
YES
NO
If yes, please provide your concerns:
8. Do you feel like there is a better way to manage your child’s asthma?
If yes, please share your thoughts/ideas:
Psychosocial and Asthma: 1. Do you feel your child’s school can provide support for your child’s asthma?
Community and Asthma: 1. Do you feel like there are things in your community, neighborhood, or home that negatively contribute to your child’s asthma? If yes, please circle or list your concerns: Poor air quality Social Support Neighborhood Cleanliness
Access to Healthcare Living Expenses Work Smoking Prevalence Old/Poor Housing Stress Other (please list)
Figure 2. “Asthma follow-up packet” for parent.
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Friend and Morrison Original Article Provider Assessment: The Patient’s Asthma Knowledge Rate the patient’s ability to complete/answer each of the following items: 1. Can you explain to me how your Asthma Action Plan works? -Patient: has full understanding (great), knows some yet needs some assistance (good), does not know/needs a lot of assistance understanding (needs work) 2. Which medicine is your rescue inhaler? Which medicine is your daily/maintenance inhaler?
Great
Good
Needs Work
Great
Good
Needs Work
Great
Good
Needs Work
Great
Good
Needs Work
Great
Good
Needs Work
-Patient: knows both (great), knows one (good), doesn’t know either (needs work) 3. Can you show me how you take your medicine for your asthma? -Patient: demonstrates all steps properly (great), knows basic steps yet still requires reminders on other steps (good), does not demonstrate appropriately (needs work) 4. What are triggers that cause your asthma to get worse? -Patient: identifies his/her triggers (great), knows some triggers, but not all (good), does not know triggers (needs work) 5. What do you feel like when you need your rescue inhaler? -Patient: identifies at least 3 symptoms (great), 1-2 symptoms (good), 0 symptoms (needs work. 6. Does having asthma mean that you cannot exercise or play? -Patient: understands need to have rescue inhaler readily available and to monitor for symptoms (great), believes that activities are limited even when not having an exacerbation, yet knows triggers and use of rescue inhaler (good), believes that activities are limited and does know triggers and/or rescue inhaler (needs work)
Great Good
Needs Work
All of the items that “Needs Work” can be addressed by education of the patients Asthma Action Plan and proper use of medication.
The items on this assessment page that are labeled “Needs Work” are being addressed during this visit by:
Demonstration followed by return demonstration by the patient
Handouts followed by verbalized understanding from the patient
Verbal Education given by the provider followed by verbalized understanding from the patient
Provider: ______________________________
Date:________________
(continued)
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Clinical Pediatrics
Figure 3. (continued) Friend and Morrison
7
Child Health Belief & Psychosocial Questionnaire Do you feel as confident about yourself as you did when you did not have asthma? If no, how do you feel different now that you have asthma?
YES
NO
YES
NO
YES
NO
Do you feel like your friends will help you with your asthma if you need it?
YES
NO
Does your school staff (teachers, school nurse, principal) know you have asthma?
YES
NO
Do you feel like your school staff will help you with your asthma if you need it?
YES
NO
Are you able to treat your asthma while you are away from your parent(s), even if it gets worse?
YES
NO
Do you feel like your parents or family will help you with your asthma if you need it? Do your friends know you have asthma? If yes, do your friends treat you the same, now that they know you have asthma?
On a scale of 0 to 10, how confident are you in handing your asthma while you are away from your parent? 0 = not confident (cannot treat your asthma on your own) 10 = very confident (you do not need any assistance to treat your asthma when parent is not around), 0
1
2
3
4
5
6
7
8
9
10
Figure 3. “Asthma follow-up packet” for child.
Acknowledgments
Declaration of Conflicting Interests
The authors thank Dr Ronald L. Tyson, DNP, DMin, CNP, PMHNP-BC, ANP-BC; FNP Distant Learning Program College of Nursing, University of Cincinnati.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Friend and Morrison Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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