It’s challenging enough to control chronic asthma in children, but youngsters who live in low-income, inner-city households face some special barriers to optimal asthma management, including their family’s difficulty paying for medication, lack of family understanding about optimal treatment, and denial by the family about treatment compliance.
The best way to deal with at least some of these issues may be a new approach to educating families about their child’s persistent asthma, said Dr. Marina Reznik, a pediatrician at the Children’s Hospital at Montefiore Medical Center in New York. She has launched a study to test the ability of community health workers to improve family awareness and understanding of optimal asthma education and to see if this results in improved patient outcomes.
Marina Reznik
The study involves randomizing Bronx families who have a child with persistent asthma to receive either standard education materials or six visits from a community health worker, every other week over the course of 10 weeks. The health workers will instruct parents on optimal asthma control therapy, teach them how to administer an inhaled corticosteroid to their young child, and then continue to monitor the therapy over a 10-week period to make sure correct treatment delivery continues. Dr. Reznik plans to compare the outcome results between the intervention and control groups over the subsequent year.
She and her associates gained additional insight into the problems that parents face with administering correct asthma treatment to their children from the results of a pair of studies that they reported in March at the annual meeting of the Eastern Society for Pediatric Research in Philadelphia.
Comparing Perceived Asthma Compliance and Reality
In one study, Dr. Reznik and her associates tested the way that parents of children with asthma perceive their compliance with an inhaled corticosteroid regimen, compared with their actual compliance. They recruited 40 parents of a child aged 2-9 years with persistent asthma who required twice-daily therapy with an inhaled corticosteroid, a total of four puffs per day. All children were patients of the community health care center run by Montefiore. The participating parents averaged 33 years old, two-thirds were Hispanic, and 29% had not graduated high school.
Each parent received an inhaled corticosteroid actuator with an attached dose counter that recorded the number of puffs delivered. Thirty days later, the researchers surveyed the parents about their adherence to the two-puffs twice-daily regimen and also checked the dose counter on the family’s actuator.
Sixteen of the 40 parents (40%) claimed they had been 100% compliant with the regimen, while the dose counters revealed that only two families (5%) had achieved complete compliance. In addition, only one parent (3%) owned up in an interview to being completely nonadherent, while the dose counters showed that four parents (10%) had actually failed to administer any treatment during the study.
The results showed that parental self-reporting is "nonreliable" for assessing compliance with an asthma regimen, Dr. Reznik said. "The results may have implications for physicians using parental self-reports in managing children with persistent asthma."
The disparity between perceived and actual adherence may derive in part from parents’ concerns about the safety of this treatment, she suggested. "They see improved symptoms [in their children], but they are terrified of the drugs. They have misconceptions." Other social factors that make life difficult and complicated for these low-income parents may play a role as well, she said.
Delivering Asthma Medication Appropriately
The second set of results that her group reported at the meeting came from a study that focused on caregiver knowledge of the appropriate way to deliver an inhaled corticosteroid. Again, the study used parents of children aged 2-9 years old seen at the hospital’s community outpatient pediatric clinic. This time, they enrolled 66 caregivers, who averaged 32 years old, with 96% of the study group comprising mothers; 27% of the parents had not finished high school, 59% were unemployed, 59% were Hispanic and 26% were black.
Among the 66 participants, 92% said that they had used a spacer when delivering the inhaled corticosteroid to their child, with 78% saying they used the spacer for every treatment, and 5% saying they never used a spacer. In addition, 97% of the caregivers said that a physician or nurse had explained to them how to use the metered dose inhaler and spacer, 91% said that a physician or nurse had demonstrated the correct treatment technique, and 49% said that at some point a physician or nurse had watched their technique for administering the drug.
A researcher then watched each caregiver deliver two puffs of the inhaled corticosteroid to a doll. Only one of the participants (2%) correctly performed every step of drug administration with the metered dose inhaler and spacer. Although 97% correctly formed a tight seal with the inhaler, the most problematic steps involved waiting the appropriate interval between puffs, done by 27%, and instructing the recipient to exhale before the treatment inhalation, done by 24%. Other steps scored on the assessment involved shaking the inhaler for at least 5 seconds before administering a puff, pressing the inhaler just once for each puff, and administering the correct number of puffs.