This thesis follows the paper based format in that Papers One and Two are stand-alone papers prepared for submission for Clinical Child and Family Psychology Review and the Journal of Clinical Child and Adolescent Psychology respectively. The relevant submission guidelines are included in the appendix (Appendix 1). Asthma is the most common childhood chronic illness affecting an estimated 1.1 million children in the UK. A substantial body of research has shown that asthma prevalence and morbidity rates are associated not only with physiological factors but also with environmental and psychosocial factors. Identifying modifiable psychosocial variables involved in the expression and outcome of asthma in children enables identification of how and where interventions could be targeted. Two papers are presented in this thesis, which aims at contribute to research in this area followed by a critical evaluation of the research process, relevance and implications of the presented papers.Paper One is a review of the literature highlighting the biopsychosocial variables involved in the onset and development of childhood asthma. A model is proposed which aims at demonstrate the bidirectional influence of many variables thought to be involved in paediatric asthma expression. One significant area within the literature highlights the extent to which behaviour problems are elevated in asthmatic children. The prognosis for children who develop significant behaviour difficulties is poor.Research has shown that the quality of parenting a child receives has a significant impact on both the child's well-being and development. Literature included in Paper One highlights the relationship between asthma and parenting. Caregivers of asthmatic children have been shown to be more hostile and critical compared with caregivers of non-asthmatic children.Intervening early with families to promote warm, consistent and positive parenting is considered one of the most effective ways to treat behaviour difficulties. Parent training programmes have emerged as the most efficacious method of intervening with and treating child behaviour difficulties and enhancing parenting skills. In spite of their demonstrated effectiveness, engagement with programmes is often poor. As a result researchers have developed self-directed and web-based interventions. Despite their apparent benefits, uptake and continued engagement remains low.Paper Two aimed at examine whether providing asthma specific information enhanced engagement with a Triple P web-based intervention and identify any pre-treatment variables that predicted engagement. The final section, the Critical Evaluation, aimed at place the research in the wider context, consider the findings from both papers, highlight additional and unexpected outcomes and discuss the implications for future studies and limitations of the thesis.

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Despite advancements in asthma treatment and diagnosis, asthma still remains the number 1 cause for hospitalizations in school-aged children. This usability study aimed to develop a child-friendly interactive narrative, Okay with Asthma v2.0, based on the Biopsychosocial Family Model using feedback from children. This fun and kid-friendly program encourages children to manage their own asthma with the help of peers, families, communities, and health care services. With these support structures, children can identify and avoid triggers, monitor their asthma, manage their condition with medications based on an action plan, and learn to live happily with asthma.

Despite advancements in asthma treatment and diagnosis, asthma still remains the number 1 cause for hospitalizations in school-aged children. This usability study aimed to develop a child-friendly interactive narrative, Okay with Asthma v2.0, based on the Biopsychosocial Family Model using feedback from children. This fun and kid-friendly program encourages children to manage their own asthma with the help of peers, families, communities, and health care services. With these support structures, children can identify and avoid triggers, monitor their asthma, manage their condition with medications based on an action plan, and learn to live happily with asthma.

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Aim: To determine whether the addition of nebulised ipratropium to the therapy of acute asthma leads to a cost-effective reduction in the mean duration of admission and time to maximum peak expiratory flow rate (PEFR). Method: Patients with an admission diagnosis of acute asthma were studied in a double-blind, placebo-controlled trial in which they received a standard therapeutic regimen of continuous intravenous aminophylline, 4-hourly fenoterol nebulisation, intravenous methylprednisolone 125mg 12-hourly, and, every four hours, either nebulised saline placebo or ipratropium bromide 500mcg in 3ml saline. Data on age, gender, initial and maximum PEFR, time to maximum PEFR, and duration of hospital stay was collected from the hospital record after discharge. Statistical techniques: 2-way contingency tables for categorical variables, 1-way ANOVA for treatment effects, and life-table analysis of the time till discharge. Results: Records of 279 of the 400 patients entered in the study were suitable for analysis after excluding re-admissions, non-asthmatics and incomplete records. Baseline comparisons of age and severity on presentation showed no significant differences. The trial group did not differ significantly from the control group with respect to either time to PEFR (respectively 21.11 hours (SD 14.3) versus 22.89 (SD 15.82)) or duration of admission (5.02 (SD 3.65) versus 5.38 (SD 3.13) 6-hour units). In a sub-group of patients (n=155) demonstrating more than 100% improvement in PEFR, the time to maximum PEFR was significantly shorter in the ipratropium group (20.35 hours SD 12.4) versus 25.20 hours (SD 17.0); p= 0.045). Conclusion: The addition of ipratropium bromide to a standard treatment regimen for acute asthma reduced the time to achieve maximum PEFR in a sub-group of patients with markedly reversible airflow limitation. Overall, however, the addition did not prove cost-effective.

The author participated in an international survey organised by the British Medical Research Council (MRC) epidemiological unit in Cardiff, Wales which set out to compare the prevalence of asthma in several countries. The motivation for participating in this study was that very little previous prevalence data for asthma is available for coloured or white children in South Africa. A protocol designed by the British MRC Epidaemiology Unit was followed. One thousand one hundred and seventy four white children aged 12 years attending a random selection of primary schools in the Southern Suburbs of Cape Town were studied. A standard MRC questionnaire on asthma was completed by parents. The subjects then underwent an exercise challenge test (ECT) which involved running on the level for six minutes. During the ECT, we measured the forced expiratory volume in 1 second (FEVl) before and after the exercise. A fall in post exercise FEVl of 15% or greater was regarded as evidence of bronchoconstriction and considered diagnostic of asthma. This method is thought to identify 70-90% of asthmatics (Anderson 1985, Lee et al 1989, Pierson 1988). Using this criterion, 52 (4.4%) of the children had asthma. The prevalence of 4.4% in this study is higher than 3.1% reported in a previous study of black children in Guguletu (Van Niekerk et al, Clinical Allergy 1979). However, the age spectrum of children was different in that study. Terblanche et al (1990) report the prevalence of exercise induced bronchoconstriction (EIB) in white and coloured children to be 5.87% and 4.05% respectively. The level of FEVl reduction for a diagnosis of EIB approved for this study was lower than usually accepted. Using conventional criteria for a diagnosis of EIB, Burr et al (1989) reported a prevalence of 7.7% in Cardiff, Wales. This study confirms that exercise induced asthma is a common problem in 12-year old white children in Cape Town.

Asthma is a chronic obstructive pulmonary disease (COPD) which affects 1 in every 12 Americans. Symptoms common to asthmatics include dyspnea, increased mucous production and airway hyperresponsiveness. While research over the past few decades has mostly established the immunological basis behind asthma, there have not been radical changes in the treatment modalities. It is believed that in many COPDs, alveolar macrophages play a critical role in disease progression. While evolutionarily, alveolar macrophages played a significant part in protecting the individual from harmful allergens, in asthma there may be an inappropriate activation of the alveolar macrophages to proteases such as cockroach allergen (CRA). Studies show that children living in inner cities with cockroach infestation are more likely to develop asthma than those that reside in rural areas with less exposure to cockroach allergens. In exposed individuals, when the alveolar macrophages come in contact with CRA, an immune cascade is initiated which sensitizes the child. Subsequent exposure to such an antigen will induce asthma like symptoms. One possible way of reducing such a response is to reduce the number of alveolar macrophages thus avoiding the pathalogical effects. Clodronate liposomes are liposomes that are encapsulated with bisphosphonate clodronate. When a macrophage phagocytoses such a liposome, the result is cellular suicide or apoptosis. In this study, we sensitized a murine model of CRA asthma and then monitored the impact of depleted alveolar macrophages using intratracheal administration of clodronate liposomes. We then studied the effect of this depletion on the recruitment of inflammatory cells such as neutrophils and eosinophils which are primary cellular contributors to the asthmatic response. Our studies show that while clodronate liposomes are effective in alveolar macrophage depletion, the subsequent inflammation through neutrophil recruitment interferes with the study of the delicate milieu of cells in the respiratory epithelium of this murine model.

Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Medicine Johannesburg, August 2013 / Asthma control is a central focus of the updated version of the GINA Guidelines, in which clinicians are encouraged to concentrate on assessment of control, defined by symptoms, lung function and the presence or history of exacerbations. Control is of critical importance in asthma and is now more important than the actual level of severity. Measures of asthma control do not necessarily perform well and all of them need to be looked at as a whole as studies have shown. Many factors have been found to be associated with poor asthma control ranging from concomitant rhinitis and co morbidities to poor compliance with medications or inappropriate inhaler technique in addition to home or environmental factors. Several factors around the home of asthmatic patients contribute to poor asthma control which includes parental smoking or smoking by other relatives within the home, biomass fuel exposure, exposure to aeroallergens and animal danders which all leads to failure in achieving control despite adequate drug therapy. This cross sectional study was conducted in 115 asthmatics children with the aim of determining the level of asthma control and home circumstances that contributes to poor asthma control. Most patients were males and blacks with 55.65% of patients having controlled asthma. Use of biomass fuel was uncommon in this study and none of the home circumstances was found to be associated with poor asthma control in this study. Day time and nocturnal asthma symptoms were significantly associated with poor asthma control. Good adherence to medications was found to be associated with asthma control similar association was not seen with good inhaler technique. The higher the FEV1 percent predicted the better the asthma control. Day time and nocturnal asthma symptoms were associated with FEV1. Results from this study need confirmation in a representative population study. Further longitudinal study is required to see if home circumstances may affect asthma control in patients that had controlled asthma.

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