Abstract
Purpose:
Social determinants of health influence how well a family manages children’s asthma. The aim of this study was to examine the influence of social determinants of health on family asthma management.
Design:
A cross-sectional exploratory study was conducted with 292 children in grades 2–5 who had current asthma and their parents to examine associations between social determinants of health and the families’ asthma management, quality of life, and health care utilization.
Methods:
Data were collected from both child and parent. Social determinants of health include the child’s race/ethnic group, age, gender, and asthma severity, the family’s socioeconomic status, language spoken in the home, and the school was the community-level variable. Parents and children completed asthma management and quality of life scales and parents reported on the children’s emergency department visits and hospitalizations for asthma.
Results:
Worse quality of life was reported by families with lower socioeconomic status and African American children. Asthma severity was associated with parents’ asthma management but not children’s asthma self-management. Families who spoke Spanish at home had the lowest socioeconomic status yet performed significantly more asthma management than English-speaking families.
Conclusions:
The findings highlight factors the clinical nurse specialist should address in educational interventions.
Introduction
Social determinants of health (SDoH) can influence how well a family manages chronic health problems in affected children. The SDoH are factors present in places where people live, work, and play that can influence health status.1 For example, living in a degraded environment that exposes families to risk and the lack of community resources for promoting health represent underlying social issues that can negatively affect health.2,3 The inequitable distribution of resources for health is a major contributor to health disparities.2 Understanding SDoH can guide clinical nurse specialists to better support their patients to improve their health status.3
Asthma is one of the most common chronic childhood conditions, affecting 6 million children in the United States.4 It presents with symptoms of coughing, wheezing, dyspnea, and discomfort with breathing and occurs episodically in response to a wide range of triggering events.4 While health care providers direct asthma management activities by prescribing medications to control asthma symptoms and advising parents on environmental strategies to implement, the day-to-day work of managing asthma in the child is the families’ responsibility.5,6 Given its episodic presentation, asthma is a complex condition for families to manage and various social determinants of health can further complicate this work.
Early in life, the responsibility for managing asthma rests heavily with the parents, who are just beginning to learn about asthma. Overtime as the child matures and enters the school system, the work to manage asthma becomes a partnership between the parent and child but must include others outside the family like coaches, school nurses, and teachers.7 Clinical nurse specialists (CNS) who work with families who have children with asthma can be found in ambulatory settings like school-based clinics or specialty care clinics, or in acute care settings such as emergency departments (ED) or hospitals. They interact with families who have a wide range of knowledge, skills, and resources for managing asthma. It is imperative that nurses recognize how social determinants of health (SDoH) can complicate asthma management and take these factors into account as they work with individual families.7 National surveys report on the prevalence of asthma and provide data related to the SDoH factors of race, ethnicity, income level, and age,4 but there are no reports in the literature on the influence of SDoH factors and family asthma management. The purpose of the study reported here was to begin to fill this gap by examining the associations between SDoH and family asthma management and quality of life.
Review of Literature
Social Determinants of Health
Social determinants of health (SDoH) are factors in the social and physical environment that contribute to health disparities.1 These factors include well-studied social characteristics such as education level, income, employment, race and ethnicity, age, and gender. Other factors focus on the contexts were people live, work, and play, including housing characteristics, neighborhood quality and safety, and community environment and resources. Groups that experience social disadvantages experience higher health risks.8 Social disadvantages include living in poorly maintained or overcrowded housing, being exposed to poor pest control, unsafe neighborhoods, or violence, and experiencing pervasive chronic stress due to perceived discrimination and inadequate family financial resources.8–10
The home, work, and neighborhood environment can present additional risks to health for children with asthma.3 The higher asthma prevalence exhibited by urban inner-city and poorer children has been well documented and is related to pervasive social disadvantages.3,10 Further, inner city children are exposed to higher levels of pollution due to increased traffic congestion.10 In fact, the proximity of the home environment to high traffic roads has been associated with increased asthma episodes among children who are members of racial and ethnic minorities.11 For example, Hispanic children in the US are 2.5 times more likely to live near heavy traffic areas than non-Hispanic white children.12
Social disadvantages are not limited to the urban population. In recent years, the problems of asthma in rural communities has also been recognized. Access to safe areas to play out-of-doors is not a problem for most rural families but exercise in the form of walking or running along country roads and highways is limited by a lack of pedestrian walkways. Families living in rural areas have fewer social service resources when compared to those available to urban and suburban families, and they are exposed to different aeroallergens and asthma triggers.13 Rural areas are often the locations for municipal dumps, waste management systems, industries that contribute to pollution of air and water, and the use of pesticides for agriculture and all are significant sources of asthma triggers.14,15 Given the social disadvantages facing rural families, Ownby postulated that asthma may in fact be under-diagnosed in this population.16
While asthma affects children of all races, ethnicities, and income levels, some children carry a disproportionate burden of asthma including those who are members of racial and ethnic minorities or are from poorer families. The recent National Health Interview Survey conducted by the Centers for Disease Control found that asthma prevalence was higher among non-Hispanic black children (15.7%) and children of Puerto Rican descent (12.9%) than among non-Hispanic white children (7.1%), and higher among children living in low income families (10.5%) than in families with income 250% or more above the Federal Poverty Level (7%).4 Notably, people with lower incomes often live in areas of greater environmental asthma triggers.17 Gender has a differential influence across the lifespan, such that in childhood more boys (60%) are diagnosed with asthma than girls (40%), but this trend is reversed in adulthood when more women than men have asthma.
Asthma Self-Management
Successful asthma management of parents and their children depends on resources in the home and the family’s social circumstances to deal with stressful and often costly situations that arise when asthma is poorly controlled.18 With 10.5 million missed days of school due to asthma each year, improving the family’s asthma management is imperative. School absenteeism translates into work absenteeism and loss of income for many families who work in poor paying and under-resourced jobs.7,13 Researchers and clinicians have developed many successful programs for improving the family’s knowledge of asthma and skills in managing asthma. The goal of asthma self-management programs is to reduce the impairments associated with asthma symptoms and thereby improve quality of life.19–21
Effective asthma self-management programs delivered in hospitals, clinics, or school settings have reduced hospitalizations and ED visits for asthma.22 A recent Cochrane review of 55 studies of school-based asthma self-management programs found that as children’s recognition of asthma symptoms and inhaler technique improved, there was an associated reduction in days with asthma symptoms and acute asthma episodes and increased school attendance.6 Improving asthma self-management is associated with decreases in missed school days, acute health care visits to the healthcare provider’s office, emergency department (ED) visits, and hospitalization for asthma, thereby reducing the burden of asthma on the family.23 Fewer missed school days translates into fewer days out-of-work and resultant income loss for the parents.17 Meta-analyses indicate that highly effective school-based asthma self-management programs are characterized by being comprehensive in scope.6 Such programs address knowledge deficits, early symptom recognition, asthma trigger avoidance or reduction, and proper use of medications.6,22 Furthermore, they actively engage the children in practicing skills, engaging in problem-solving, and working with parents for implementing home strategies for managing asthma.6
Many school-based programs are created by teams of healthcare providers working in collaboration with schools. The CNS can play an integral role in these collaborations by planning school-based interventions, serving as a vital resource to school nurses, and facilitating intervention delivery.24 Understanding the SDoH of the school population can guide the CNS in adapting the intervention to address population health needs.1,3
Methods
The purpose of this study was to examine the influence of social determinants of health on families’ work to manage asthma, their asthma-related quality of life, and health care utilization. A cross-sectional study design was used to examine the baseline data collected from school-aged children who have asthma and their families. The Asthma Health Model7 was the theoretical framework guiding this study. It indicates background factors influence the family asthma management practices that in turn affect health outcomes.7 The SDoH factors of socioeconomic status (SES), race/ethnicity, child’s age, gender, and language spoken in the home are identified as background factors as well as asthma severity. Family asthma management includes the parents’ home asthma management and the children’s asthma self-management and the children’s skill in using a metered dose inhaler (MDI). The health outcomes include emergency department (ED) visits and hospitalizations for asthma, and the parents’ and children’s asthma-related quality of life (QOL). The research questions guiding this study were:
What are the relationships between SDoH variables, and parents’ and children’s asthma self-management, MDI skill, and QOL in a community-based sample?
What are the differences in individual and family SDoH variables, asthma self-management, MDI skill, quality of life, ED visits and hospitalizations between majority and minority serving elementary schools?
Study Ethics
Before commencing the study, the protocol was reviewed by the University Institutional Review Board and approved. Consent from parents and assent from children were obtained prior to collecting data from both parents and children. All public documents (e.g., consent, assent, recruitment materials, questionnaires) were written in a dual-language English-Spanish format. Further, to be consistent with the policy of the school district that served the largest group of lower SES children, all parent documents were written at the 5th grade reading level or lower. Our team has tested our materials in an earlier pilot study that demonstrated good readability and comprehensibility of our written materials.25 To thank them for their time in completing the surveys, Walmart gift cards were given to parents ($20) and children ($10).
Sampling & Recruitment
The sample inclusion criteria for this study of childhood asthma were school-aged children in (a) grades 2 – 5, (b) who have a health care provider diagnosis of asthma, and (c) who have current asthma which is defined as experiencing asthma symptoms in the previous 12 months. Children and parents could speak either English or Spanish. The exclusion criteria were having another chronic respiratory condition that would preclude basic asthma management such as bronchopulmonary dysplasia or cystic fibrosis because these conditions both have additional complex treatment therapies.
Eligible children were recruited from 33 elementary schools located in ‘rural-adjacent’ communities. Rural adjacent refers to communities that would, in the previous decade, be categorized as rural but the increasing out-migration of families from higher-taxed urban centers to nearby lower-taxed rural areas have led to massive population growth and the suburbanization of formerly rural communities. Nevertheless, the environment in which children live, play, and go to school retains its agricultural nature as evidenced by Bi and colleagues’ study of indoor home environments that found allergens (i.e., pollen, mold, dust) consistent with farming communities.26 School nurses or school nurse assistants sent letters to homes of children with diagnoses of asthma to invite the family to participate. After 2-weeks, follow-up telephone calls were made from the school nurse office to non-responding families to (a) determine that they had received the letter and (b) ask if they were willing to let the researcher contact them to discuss the study. Fully 95% of the families indicated they had received the letter and some indicated their child no longer had asthma (10%), they were too busy (10%) or they were not interested (5%), and the remaining 75% (n=394) granted permission for the researcher to contact them.
A bilingual project coordinator contacted the families to explain the study and verify the child met the sample inclusion criteria. Several families were eliminated at this stage because the child did not have current asthma (15%) or the child had another diagnosis (one had cystic fibrosis, one had cancer and was too ill to attend) that precluded participation. Other families declined to participate due to busy schedules or indicated their children’s asthma was ‘well controlled.’ The final sample was composed of 292 children (74% of 394 agreed to participate).
Data Collection & Measures
A meeting was scheduled with families who agreed to participate in the study to enroll them and collect data. The meeting was scheduled at a time and location convenient to the families – most often this took place in their home, but occasionally meetings were arranged at the child’s school or at a public library in a small private room. Data were collected in face-to-face meetings from both the parents and children using questionnaire booklets. The survey instruments were combined into booklets, one booklet contained all the children’s instruments and one booklet had all the parents’ instruments. The booklets included questionnaires asking about individual and family level variables that reflect the SDoH factors, as well as asthma management, QOL, ED visits and hospitalizations for asthma. All of the instruments had been used previously with a similar population based on children’s ages (7–12 years) and diverse racial/ethnic groups and were found to have good reliability with this population. Children were assisted in completing their booklets by the graduate research assistant (GRA) who explained read the individual items and response options aloud to the children who in turn then provided their answer choice for the items.
Individual background variables.
The individual level variables include demographic factors like the child’s race and ethnicity, gender, and child’s age, as well as the severity of the child’s asthma. Asthma severity was measured with the 3-item Severity of Chronic Asthma scale27 that asks the parents to rate the frequency of daytime asthma symptoms, nighttime asthma symptoms, and days with limited activity over the past month using a 4-point ordinal response scale that ranges from “0–2 times a week” to “daily.” The items are summed for a continuous scale score ranging from 3–12. The scale is easy for parents to complete and has demonstrated acceptable reliability and validity.27
Family background variables.
Family factors include the socioeconomic status (SES) and the language spoken in the home. The family SES was calculated using the parents’ education levels and occupations with the Hollingshead Four Factor Index calculation that yielded a continuous variable (possible range of 8 – 66).28 The language spoken in the home was documented by the bilingual GRA during the data collection visit.
Asthma management.
Parents’ asthma management was assessed with the 16-item Management Behavior Survey that measures the frequency of parents’ asthma symptom prevention and treatment activities.29 Items are scored on a 5-point scale from 1 for “never” to 5 for “always.” The items are summed for a total scale score and it has good internal consistency (α = .82).29 Children’s asthma self-management was assessed by the child’s responses to the 13-item Asthma Behavior Inventory.23 Items are scored on a 5-point scale from 1 for “never” to 5 for “always.” The tool measures children’s self-reported asthma treatment and preventive behaviors and the internal consistency (α = .76) was good with a school-age sample.
We also measured the child’s skill in using a metered dose inhaler (MDI).30 The child’s inhaler skill was scored by observing the child use a placebo inhaler. An 8-item scale listing the correct steps was scored by the trained GRA who checked off each step that was performed.30 The scale was developed by Kelly and colleagues and tested at a summer asthma camp to evaluate changes in the campers’ MDI skill in response to training sessions held during camp.30 The scale demonstrated good reliability and validity. While the observation scale is not product-specific, its use is limited to propellant-based inhalers and does not cover dry-powder inhalers.
Health outcomes.
Parents provided information on their child’s ED visits and hospital stays in the past 12 months for asthma episodes. Quality of life (QOL) was assessed both in parents and children. Children’s QOL was measured with the 23-item Pediatric Asthma Quality of Life scale that has 3 subscales; a 10-item symptom subscale, 8-item emotional function subscale, and 5-item activity subscale.31 The items are rated on a 5-point scale with 5 for “never” to 1 for “always.” Internal consistency was good for the total scale score (α = .92), the symptom subscale (α = .85), the emotional function subscale (α = .83), and the activity subscale (α = .72). The total scale and the subscale items are summed, with higher scores indicating better QOL.
The parent’s QOL was measured with the 13-item Pediatric Asthma Caregiver’s Quality of Life scale with two subscales including a 4-item family activity subscale and a 9-item emotional functioning subscale.32 Items are scored on 7-point response scales that assessed either frequency or degree of worry. For example, 1 represented “all the time” or “very, very worried” while 7 represented “none of the time,” or “not worried.” The total scale and subscale items are summed with higher scores indicating better QOL. The internal consistency was good for the total scale score (α = .89), the emotional function subscale (α = .84), and the family activity subscale (α = .85).
Community-level variable.
The elementary schools served as the proxy measure for the community level variable because they could be differentiated into primarily majority and primarily minority schools based on the percentage of students eligible for the free/reduced school lunch program and the schools’ reported racial/ethnic student enrollment report. Schools that were designated as “majority schools” had fewer than 50% of their students enrolled in the free/reduced lunch program (actual range = 15% – 45%) and 76.5% of the students were non-Hispanic whites. Schools that were designated as “minority schools” had more than 50% of their students enrolled in the free/reduced lunch program (actual range = 64% – 94%) and 85.3% of the students were racial or ethnic minorities.
Data Analysis
A GRA entered data from the parent’s and child’s questionnaire booklets into a password-protected computer file that was then double checked by a second GRA for accuracy of data entry. Descriptive statistics were run on the variables (see Table 1) and checked for outliers. To answer the first research question, correlation procedures were run to identify associations between the continuous SDoH (i.e., SES and asthma severity) variables and QOL, asthma management, and MDI skill, while t-tests or ANOVA were run to assess associations between categorical or nominal data (i.e., gender, race/ethnic group, language spoken at home) and the continuous variables of asthma management, MDI skill, QOL, ED visits, and hospitalizations. To answer the second research question about differences in the student populations in majority versus minority serving schools, t-tests and ANOVA were run on continuous variables and chi-square were run on nominal or categorical variables.
Table 1.
Sample Descriptive Statistics
| M (SD) | N (%) | |
|---|---|---|
| School Factor | ||
| Majority School | 12 (37%) | |
| Students | 79 (27%) | |
| Minority School | 21 (63%) | |
| Students | 213 (73%) | |
| Family Factors | ||
| Socioeconomic Status | 30.71 (13.86) | |
| Spanish Language | 73 (25%) | |
| Individual Factors | ||
| Asthma Severity | 4.15 (1.35) | |
| Asthma Management | ||
| Parent Asthma Management | 54.03 (10.11) | |
| Child Asthma Self-Management | 49.07 (9.30) | |
| Metered Dose Inhaler Skill | 4.91 (1.53) | |
| Asthma-related Quality of Life (QOL) | ||
| Parent, total QOL | 69.58 (15.83) | |
| Parent, emotional functioning QOL | 48.90 (10.86) | |
| Parent, family activity QOL | 54.10 (10.15) | |
| Child, total QOL | 84.71 (19.81) | |
| Child, emotional functioning QOL | 30.23 (7.77) | |
| Child, asthma symptoms QOL | 36.38 (9.57) | |
| Child, activity limitations QOL | 18.21 (4.78) |
Results
The sample was composed of 186 boys (63.7%) and 106 girls (36.3%) who were an average of 8.82 years old (SD = 1.25) and mothers were 36.08 years old (SD = 7.19). The ethnic and racial composition of the sample was 168 (57.5%) Hispanic, 62 (21.2%) African American, 55 (18.8%) non-Hispanic white, and 7 (2.3%) other groups. Spanish was the language spoken in 73 (25%) of the homes.
The associations between the individual-level SDoH factors of gender, age, racial/ethnic group, asthma severity, and the families’ asthma management and QOL were mixed. The child’s age and gender were not associated with asthma management, QOL, ED visits, or hospitalizations for asthma.
There were significant differences between the racial/ethnic groups and parents’ asthma management, and parents’ and children’s QOL (see Table 2). Hispanic children had significantly more ED visits and their parents performed more asthma management than white families. African American children had significantly worse emotional functioning QOL than white children and worse total QOL, asthma symptom QOL, and activity limitations QOL than both white and Hispanic children. White parents had significantly better emotional functioning QOL than Hispanic parents and better family activity QOL than African American parents. In addition, SES was significantly different between racial and ethnic groups in the sample, F(2,280) = 82.43, p <.001. Hispanics had the lowest SES, followed by African Americans, and then non-Hispanic whites had the highest SES.
Table 2.
Differences in Asthma Management and Outcomes Between Race/Ethnic Group
| Race/Ethnic Group | White | Hispanic | Black | |||||
|---|---|---|---|---|---|---|---|---|
| N | 55 | 168 | 62 | |||||
| Variable | m (SD) | m (SD) | m (SD) | F | p | |||
| Asthma Severity | 4.13 (1.48) | 4.17 (1.36) | 4.03 (1.21) | .24 | .78 | |||
| Family SES | 46.25 (10.39) | 24.42 (10.87) | 33.61 (12.39) | 82.43 | <.001 | |||
| Asthma Management (AM) | ||||||||
| Parent AM | 50.82 (8.95) | 55.54 (10.04) | 54.10 (9.18) | 4.97 | .008 | |||
| Child AM | 48.56 (7.70) | 48.68 (10.01) | 50.42 (8.80) | .87 | .42 | |||
| Metered Dose Inhaler | 5.13 (1.49) | 4.85 (1.59) | 4.86 (1.47) | .70 | .50 | |||
| Quality of Life (QOL) | ||||||||
| Parent: | ||||||||
| Total QOL | 74.14 (14.07) | 69.01 (15.20) | 67.69 (17.49) | 2.93 | .06 | |||
| Emotional function QOL | 52.30 (9.44) | 48.08 (10.63) | 48.48 (11.51) | 3.30 | .04 | |||
| Family activity QOL | 22.04 (5.55) | 21.00 (5.83) | 19.21 (6.93) | 3.40 | .04 | |||
| Child: | ||||||||
| Total QOL | 89.24 (19.84) | 86.36 (19.33) | 76.94 (19.34) | 7.05 | .001 | |||
| Emotional function QOL | 32.04 (7.67) | 30.36 (7.63) | 28.31 (7.96) | 3.46 | .03 | |||
| Asthma symptoms QOL | 38.00 (9.80) | 37.36 (9.37) | 32.08 (9.15) | 8.21 | <.001 | |||
| Activity limitations QOL | 19.20 | 4.31 | 18.63 | 4.51 | 16.55 | 5.20 | 5.90 | .003 |
| ED Visits | .18 | .48 | .64 | 1.34 | .69 | 1.24 | 3.52 | .03 |
| Hospitalizations | .22 | .88 | .16 | .67 | .50 | 1.87 | 2.23 | .11 |
Families who spoke only Spanish had the lowest SES (m = 18.10, SD = 6.11). Children in Spanish-speaking families had lower MDI skill scores, t = 2.05, p = .04, and performed less asthma self-management, t = 2.98, p = .003, than children in English-speaking families. Whereas Spanish-speaking parents performed more asthma management than English-speaking parents, t = −2.03, p = .04.
The child’s asthma severity was significantly inversely correlated with children’s and parents’ QOL and ED visits, and significantly correlated with parents’ asthma management (see Table 3). Asthma severity was not significantly associated with the children’s asthma self-management, MDI skill, and was not different between race/ethnic group or gender.
Table 3.
Correlations Between SES, Asthma Severity, Asthma Management, & QOL
| Asthma Severity | SES | |||
|---|---|---|---|---|
| r | p | r | p | |
| Asthma Management (AM) | ||||
| Parent AM | .13 | .03 | −.15 | .009 |
| Child AM | .06 | .32 | .04 | .46 |
| Metered Dose Inhaler | −.03 | .67 | .09 | .13 |
| Quality of Life (QOL) | ||||
| Parent: Total QOL | −.34 | <.001 | .16 | .006 |
| Emotional function QOL | −.31 | <.001 | .18 | .002 |
| Family activity QOL | −.32 | <.001 | .10 | .11 |
| Child: Total QOL | −.21 | <.001 | .16 | .007 |
| Emotional function QOL | −.17 | .005 | .20 | <.001 |
| Asthma symptoms QOL | −.21 | <.001 | .11 | .07 |
| Activity limitations QOL | −.15 | .008 | .11 | .07 |
| ED Visits | −.31 | <.001 | −.16 | .007 |
| Hospitalizations | .09 | .14 | .007 | .90 |
The families’ SES was significantly inversely correlated with parents’ asthma management and ED visits and positively correlated with parents’ and children’s total QOL and emotional functioning QOL (see Table 3). In contrast, SES was not significantly associated with children’s asthma management, MDI skill, asthma symptom QOL, or activity limitations QOL.
Differences in SDoH between majority schools and minority schools also showed mixed results (see Table 4). As expected, more racial and ethnic minorities attended those schools designated as minority serving schools than attended majority serving schools, X2 (2) = 59.89, p < .001. Children who attended minority schools had significantly lower family SES, more ED visits, lower MDI skill scores, and poorer total QOL than children who attended majority schools. Whereas, the children’s asthma severity, asthma self-management, and hospital stays were not significantly different between minority and majority schools.
Table 4.
Differences Between Majority-Serving and Minority-Serving Schools
| Schools: | Majority | Minority | ||||
|---|---|---|---|---|---|---|
| Variable | m | SD | m | SD | t (288) | p |
| Asthma Severity | 4.07 | 1.32 | 4.18 | 1.36 | −.56 | .57 |
| Family SES | 40.55 | 12.53 | 27.58 | 12.78 | 7.43 | <.001 |
| Asthma Management (AM) | ||||||
| Parent AM | 51.97 | 8.95 | 54.68 | 10.38 | -1.97 | .05 |
| Child AM | 49.54 | 8.03 | 48.92 | 9.68 | .49 | .62 |
| Metered Dose Inhaler | 5.33 | 1.4 | 4.78 | 1.55 | 2.65 | .009 |
| Quality of Life (QOL) | ||||||
| Parent: Total QOL | 74.09 | 14.28 | 68.16 | 16.06 | 2.77 | .006 |
| Emotional function QOL | 52.22 | 10.05 | 47.85 | 10.92 | 2.95 | .003 |
| Family activity QOL | 22.03 | 5.38 | 20.35 | 6.29 | 2.01 | .05 |
| Child: Total QOL | 89.01 | 19.08 | 83.36 | 19.88 | 2.10 | .04 |
| Emotional function QOL | 31.76 | 7.59 | 29.74 | 7.78 | 1.90 | .06 |
| Asthma symptoms QOL | 38.19 | 9.21 | 35.68 | 9.63 | 1.92 | .06 |
| Activity limitations QOL | 19.07 | 4.31 | 17.94 | 4.9 | 1.74 | .08 |
| ED Visits | .27 | .98 | .65 | 1.25 | -2.63 | .01 |
| Hospitalizations | .10 | .62 | .29 | 1.18 | −1.75 | .20 |
Discussion
In this community-based sample of school-aged children who had asthma and their parents, SDoH had variable contributions to the families’ work to manage asthma and their QOL. The individual and family-level factors of racial/ethnic group membership, SES, and language spoken at home were significantly associated with asthma management and QOL. The two SDoH factors of racial/ethnic group membership and SES may be confounding factors because the Hispanic families had the lowest SES followed by the African American families in this sample. Consistent with national surveys more children from lower SES families had more ED visits for asthma in the past year.4
In this sample, more Hispanic children had ED visits than African American or white children. Interestingly, their parents reported they performed significantly more asthma management behaviors than families with higher SES. This latter finding was most notable among the Spanish-speaking parents who reported the lowest SES of the entire sample, yet they performed significantly more asthma management than the English-speaking families. Parents’ asthma management includes strategies for reducing the child’s exposure to environmental triggers as well as managing their medications. Many of the home environmental strategies require careful household cleaning and reducing contact or exposures to aeroallergens by closing windows and keeping children indoors during high pollen seasons. These environmental strategies require consistent awareness and effort but do not necessarily require added expense and as such provide the parents with feasible and affordable activities to help keep their child healthy.23
In terms of community-level influences, children who attended minority schools had more ED visits for asthma, worse MDI skill, and reported worse QOL than children who attended majority schools. The schools are a proxy measure for the children’s neighborhoods as they draw their students from the geographic area immediately around the school. In this sample, children were not bused to distant schools, but rather went to ‘neighborhood’ schools. The lower MDI skill is a possible contributing factor to the child going to the ED for poorly controlled asthma. Many studies of asthma management have found that fully 50% of participants do not use their inhaler properly and as a result have higher health care utilization for asthma exacerbations.19
Differences in parents’ and children’s asthma-related QOL were associated with the family SES and racial/ethnic group. Parents and children in higher SES families reported better QOL in all domains. African American children had worse QOL than other children. The QOL questionnaire measures how much they are bothered by asthma symptoms, activities are limited by asthma, or how worried they are about asthma.31,32 The parents’ degree of worry about asthma may reflect the financial impact they experience when their children have asthma episodes due to the out-of-pocket expenses and loss of work income that are difficult to weather when finances are limited.3,13
It is not clear why African American children have worse QOL than other children, including Hispanic peers who are from low SES families or who are also members of a racial/ethnic minority group. Although the parents of African American children report significantly worse family activity QOL. It is possible that the restrictions asthma imposes on their families and not being able to participate in desired activities like their peers, may contribute to the African American children’s worse QOL.
Finally, increased asthma severity was associated with worse QOL for both the child and their parent. More frequent asthma symptoms, despite medications being used, can increase the parents’ worry about asthma and negatively affects daily life. Additionally, parents performed more asthma management when their children have more severe asthma. Interestingly, we found no association between asthma severity and the children’s asthma self-management or MDI skill.
Implications.
The findings do highlight areas where the CNS can and should intervene. At a minimum, parents and children need to be assessed for their understanding about asthma and asthma management and then information provided to fill in gaps in knowledge. Most children can benefit from skills training on how and when to use an MDI. However, providing age-appropriate programs that are comprehensive in scope and review all aspects of asthma management can ensure that families are provided with the knowledge and skills needed to successfully manage children’s asthma. There are many brief programs that can be implemented in community settings like schools, churches or library community rooms, or alternately in education units of outpatient clinics or hospitals. Ideally, the choice of setting for delivering the education program should not be based on the convenience to the educator but rather to be accessible to families. Even if programs are designed and delivered to the children with asthma, ideally, materials should be sent home for the parents to review to be able to reinforce information and monitor the children’s practice to actively engage the parents in the learning process. It is critical that educational and written materials be available in the language spoken in the home to ensure that all families can benefit from the program. The present study used parent materials that were written at a 5th grade reading level and in a dual-language format to be comprehensible to parents with lower educational preparation.
Limitations.
Generalizability of the results are limited by the use of a convenience sample drawn from one region of the country. Nevertheless, the findings may have implications for CNSs and other health care providers who work with families who live in non-urban settings. A further limitation was the reliance on parental self-report for the children’s ED visits and hospitalizations for asthma in the past year. Although self-report data is subject to recall bias, health care utilization for acute asthma episodes is a unique and memorable event for a family that self-report is accepted by health care providers when evaluating care. Further, health care utilization data could not be confirmed as there were no hospitals or urgent care centers located in the school districts and all families had to travel to larger urban centers for health care.
Conclusion
It is important for CNS to recognize that SDoH can affect the families’ work to manage children’s asthma. Asthma symptoms present at different times in response to different triggers, thus making it a somewhat unpredictable condition for the child and family to manage. When designing health education programs for childhood asthma, the CNS needs to take these factors into account to improve asthma knowledge and family asthma management behaviors. Ideally the CNS should use each healthcare encounter as an opportunity to assess children’s MDI skill and asthma knowledge, confer with parents about asthma home management, and then provide education and skills practice based on the family’s unique needs.
Footnotes
The author reports no conflicts of interest.
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