Asthma is the most common long-term condition in children in the United Kingdom (UK). Asthma-related hospitalisations and mortality are disproportionally higher in the UK, compared with other European countries, however the reasons for this disparity remain unclear. A putative explanation is that that prevalence of suboptimal asthma control in children in the UK is higher than in continental Europe. If this is indeed correct, then the drivers of suboptimal control, such as poor adherence to therapy resulting from poor understanding of the role of preventer medication (inhaled corticosteroids (ICS)) in UK children would be of significant clinical interest. Therefore, in this thesis, I sought to first identify the levels of asthma control and medication adherence in a non-random sample of London secondary school children. Then, I used focus groups to further highlight the barriers to good medication adherence, and generate insights into potential solutions. To achieve these aims, I developed and implemented an online questionnaire to be delivered in schools, which included the validated Asthma Control Test (ACT). Methods: This thesis is divided into three main sections. The first and second sections include original data from an observational research study, which collected data about asthma control, from 24 London secondary schools between December 2014 and March 2016. The aim of the first section was to assess current levels of asthma control and medication adherence among children with asthma in London secondary schools. Data were collected using an online questionnaire, which included the validated ACT to measure asthma control, as well as additional questions about knowledge, healthcare use, medication use, school attendance, lifestyle and emotion and behaviour, using the validated Me and My School (M&MS) questionnaire. The second section of this thesis includes data generated from six focus groups, conducted in four London secondary schools with 56 students. In order to generate data to inform future interventions, discussions focused on the barriers to medication adherence among teenagers, and how these barriers could be addressed. The third section comprises a systematic review of school-based self-management interventions for children with asthma. The review uses a mixed-methods approach, and includes both quantitative and qualitative study data. A process evaluation is also included, to identify intervention elements that are associated with implementation success. Results: 766 children with asthma from 24 schools were surveyed. Almost half of the students (45.7%; n = 350) had poor asthma control by ACT score. Adherence with asthma medication was low, regardless of asthma control (56.2% self-reported forgetting to use their ICS "preventer" inhaler; 29% self-reported not using their SABA "reliever" inhaler when they needed it, at least some of the time). Health care involvement was relatively high, with at least one unplanned GP visit, due to asthma in the previous four weeks, reported by 28.1% of students; at least one unplanned hospital visit was self-reported by 15.7% of students; and at least one unplanned school nurse visit due to asthma was self-reported by 16% of students. At least one whole school absence was reported by 20.9% of students. Unplanned medical care and school absences were higher among children with poor asthma control, according to the ACT. Themes from focus groups suggested that social stigma, fear of embarrassment, forgetfulness, and incorrect attitudes towards medication were all contributory factors to poor medication adherence. Communications with healthcare professionals were also identified as key unmet needs of teenagers with asthma. The findings from the meta-analyses, included in the systematic review of school-based self-management interventions, showed that such interventions were effective in improving several outcomes, largely related to healthcare use. These included hospitalisations, emergency department (ED) visits, and health-related quality of life. There was no evidence that school-based interventions improved school absences, experiences of day and night time symptoms, or the use of medication. The findings from the analysis of the process evaluation studies showed that a theoretical framework is important in the development of a successful intervention. Conclusions: First, in a large non-random sample of secondary school children with asthma, the proportion of children with suboptimal control is worryingly high, and this is associated with general poor adherence to prescribed therapy asthma. Second, focus groups identified practical and social barriers to good adherence, that should be addressed in future studies. Third, previous studies suggest that school based interventions are effective in reducing incidences of unplanned and urgent healthcare use. The systematic review included studies that included relatively hard-to-reach populations, suggesting that such interventions may be effective across diverse populations, including those considered hard-to-reach. The findings in this thesis informed the development of a school-based self-management intervention, to be piloted in London secondary schools, and an NIHR-funded global research group award on improving asthma control in African children.

L’objectif général de la thèse était d’étudier le rôle des déterminants sociaux dans l’asthme avec un intérêt particulier pour des aspects méthodologiques de caractérisation du contexte social de résidence.La première partie de la thèse visait à étudier l’hypothèse d’une association entre le niveau socioéconomique (NSE) et la pollution de l’air qui est un facteur de risque important de l’asthme. Nous avons étudié spécifiquement l’association entre le NSE évalué à un niveau individuel (niveau d’études et catégorie socioprofessionnelle) et contextuel (taux de chômage du quartier de résidence) en lien avec l’exposition au dioxyde d’azote (NO2), un marqueur du trafic routier, dans 16 villes d’Europe occidentale (n=5692, 3 cohortes). Dans les analyses stratifiées par ville, nous avons observé que le NSE individuel n’était généralement pas associé au NO2, alors que l’indicateur contextuel était associé positivement et significativement au NO2 dans la majorité des villes.La deuxième partie de la thèse visait à mieux comprendre l’association entre le NSE et le contrôle de l’asthme, objectif majeur de la prise en charge thérapeutique. Ce travail a d’abord porté sur des aspects méthodologiques d’évaluation du contexte social de résidence dans la cohorte E3N (Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l’Education Nationale). La comparaison de trois indices de désavantage (n=63888) a mis en évidence l’intérêt de l’indice FDep (French Deprivation Index) pour caractériser le contexte de résidence de cette cohorte spécifique de femmes âgées avec un NSE relativement élevé comparé à celles de la population générale française. Ce travail a ensuite porté sur l’étude de l’association entre le NSE, individuel et contextuel, et le contrôle de l’asthme dans l’étude Asthma-E3N, une étude cas-témoin sur la santé respiratoire, nichée dans la cohorte E3N. Parmi les 2258 femmes avec un asthme actuel, les femmes avec un niveau d’études moyen (OR= 1.2 (1.0 ; 1.6)) ou bas (1.9 (1.4 ; 2.6)) avaient significativement un moins bon contrôle de leur asthme que celles avec un niveau d’études élevé (≥Bac+3). Les femmes qui résidaient dans les quartiers les plus désavantagés avaient plus fréquemment un asthme non contrôlé, quel que soit leur niveau d’études.Ces résultats montrent l’importance de prendre en compte le niveau socioéconomique au niveau individuel et contextuel dans l’étude des facteurs de risque de l’asthme. / The general aim of the thesis was to study the role of social determinants in asthma with a particular focus on methodological aspects to characterize neighborhood social context.The first part of the thesis aimed to investigate the hypothesis of a differential exposure to air pollution, an important risk factor for asthma. Specifically, we studied the association between socioeconomic position (SEP) assessed at individual-level (educational level and occupational status) and neighborhood-level (unemployment rate) and exposure to nitrogen dioxide (NO2), a marker of traffic exhaust, in 16 western European cities. In stratified analyses, including 5692 participants from three European cohorts, association between individual SEP and NO2 were generally weak and inconsistent in direction. The neighborhood unemployment rate was positively and significantly associated with NO2 in most of the cities studied.The second part of the thesis aimed to better understand the association between socioeconomic position and asthma control, the main target of asthma management. We first focused on methodological aspects to characterize neighborhood social context in the E3N cohort. We compared three indices of deprivation and showed that the French Deprivation Index was the most appropriate to measure neighborhood social context in this specific cohort composed of elderly women with higher socioeconomic profile than the elderly women in the general French population. We then investigated the association between SEP, at individual- and area-level, and asthma control in Asthma-E3N, a case-control study on asthma nested in the E3N cohort. Including 2258 women with current asthma, the analysis showed that women with medium and low educational level had more often uncontrolled asthma than women with high educational level. Women living in deprived neighborhood had more often uncontrolled asthma independently of their educational level.

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INTRODUCTION: Asthma is the most prevalent chronic disease in children, disproportionately affecting children from racial or ethnic minority groups and low-income families. Boston Medical Center’s Pediatric Primary Care Center serves these patient populations predominantly from the surrounding neighborhoods. It has been found that there are gaps in asthma care including diagnosing asthma in infants and young children, under-prescribing of preventive medication in all age groups, and variable management of children with poorly controlled asthma. In alignment with the accountable care organization model, health care professionals at BMC are using evidence-based care and population-based approaches to reduce asthma morbidity and thus improve the quality of life for patients with asthma and their families. METHODS: A quality improvement initiative was conducted at BMC’s Pediatric Primary Care Center. The aim was to develop routine surveillance of asthma control for the clinic population in order to identify and intervene on patients who have poorly controlled asthma. The Asthma Control Test (ACT) and the Test for Respiratory and Asthma Control in Kids (TRACK) were adapted into practice as validated patient-parent-reported tools to use to assess asthma control at all primary care office visits. Process measure included the percentage of visits with a documented asthma control testing in the electronic medical record. Outcome measures included (1) percentage of patients with poorly controlled asthma presenting to the clinic, as indicated by low ACT/TRACK scores, and (2) percentage of visits with a documented provider action in response to low ACT/TRACK scores. Iterative Plan, Do, Study, Act (PDSA) cycles optimized results; process and outcome measures were analyzed on run charts for trends. RESULTS AND CONCLUSIONS: Patient-centered strategies for visits and population-based systems to analyze outcomes are effective at delivering quality care for BMC’s pediatric asthma patient population. Following the implementation of routine asthma control screening in primary care, the percentage of visits with documented ACT/TRACK scores went from a baseline of 8% to 86%. Week to week variation was mostly attributed to higher patient visit volume beginning in the Fall season when epidemiologically there is a substantially increased frequency of asthma exacerbations in children. A median of 23% of patients report poorly controlled asthma during their visit. The percent of visits with documented provider action increased from 87% to 95% during this quality improvement initiative, indicating that patients were receiving targeted care needs including medication management and asthma education in response to low ACT/TRACK scores. However, consistent and timely delivery of preventive care services continues to be a challenge, particularly for a clinic serving high-risk, underserved, and culturally diverse patient populations. / 2020-06-17T00:00:00Z

Introdução: Ainda que resultados de ensaios clínicos preconizem que o controle da asma possa ser obtido, as evidências epidemiológicas sugerem que há uma significante lacuna entre as metas terapêuticas e o grau corrente de controle da doença obtido na população geral. Assim, o desafio que se estabelece é desenvolver estratégias que permitam atingir e manter o controle da asma. Objetivo: avaliar o efeito de um programa educativo ambulatorial individualizado em pacientes com asma não controlada. Métodos: Estudo prospectivo envolvendo pacientes com idade igual ou maior que 14 anos, com asma não controlada, recrutados a partir do ambulatório de um hospital universitário. O estudo foi conduzido antes e depois de uma intervenção educacional para asma. Após uma visita ambulatorial de rotina, os participantes respondiam a questionário estruturado para avaliar o grau de controle da asma, os escores de qualidade de vida (questionário de Juniper) e a técnica inalatória. Os participantes também foram submetidos a testes de função pulmonar. Após, eles participaram de um programa educativo em asma que consistia de uma sessão inicial individualizada de 45 minutos e de entrevistas telefônicas de 30 minutos em 2, 4 e 8 semanas. Todos os participantes foram reavaliados após 3 meses. Resultados: 63 pacientes completaram o estudo. Na segunda avaliação, foi observada significante melhora no grau de controle da asma (p<0, 001): 28 pacientes (44,4%) passaram para asma parcialmente controlada e 6 (9,5%) para asma controlada. Também, o volume expiratório forçado no primeiro (VEF1) melhorou de 63,0±20,0% para 68,5±21.2% do previsto (p=0, 002) e os escores de qualidade de vida melhoraram em todos os domínios (p<0,05). A proporção de pacientes com técnica inalatória adequada melhorou significativamente de 15,4% para 46,2% (p=0, 021) para aqueles em uso do aerossol dosimetrado e de 21,3% para 76.6% (p<0, 001) para aqueles em uso de dispositivo em pó. A análise de regressão logística identificou a técnica inalatória incorreta na primeira avaliação independentemente associada com a resposta favorável à intervenção educativa. Conclusão: Este programa educativo para pacientes asmáticos ambulatoriais resultou em melhora do grau de controle da doença. Também houve significante melhora no VEF1 e nos escores de qualidade de vida. A técnica inalatória incorreta na avaliação inicial foi preditora de resposta favorável à intervenção educativa. / Introduction: Although the results of clinical trials advocate that asthma control can be reached in most patients, the epidemiologic evidence suggests that there is a significant gap between the treatment goals and the current level of asthma control achieved for the general population. Therefore, the challenge that remains is to find management strategies to ensure that this control is achieved and maintained. Objective: To evaluate the effect of an individualized education program on the level of asthma control. Methods: A prospective study involving patients aged 14 years or older, with uncontrolled asthma, recruited from the asthma outpatient clinic of an university hospital. The study was conducted in two phases (before and after the educational intervention). After a routine medical visit, the participants completed a structured questionnaire in order to assess the level of asthma control, the quality of life (Juniper questionnaire) and inhalation techniques. The participants also underwent pulmonary function testing. Subsequently, they participated in an asthma educational program, which consisted of one individualized 45 min session and of a 30 min phone interview at 2, 4 and 8 weeks. The participants were reevaluated after three months. Results: 63 patients completed the study. Between the first and second evaluations, there was a significant improvement in the level of asthma control (p<0.001): 28 (44.4%) changed to partly controlled disease and 6 (9.5%) to controlled disease. Also, the forced expiratory volume in the first second (FEV1) improved from 63.0±20.0% to 68.5±21.2% of predicted (p=0.002) and the quality of life scores improved significantly in all domains (p<0.05). The proportion of patients with adequate inhalation technique improved significantly from 15.4% to 46.2% (p=0.021) for those in use of metered-dose inhaler (MDI) and from 21.3% to 76.6% (p<0.001) for those in use of dry powder inhaler. Logistic regression analysis identified incorrect inhaler technique in the first evaluation independently associated with significant response to the educative intervention. Conclusions: This educational program for patients attending an asthma outpatient clinic resulted in an improvement on the level of asthma control. Also, there was significant improvement in FEV1 and in quality of life scores. Incorrect inhaler technique in the first evaluation was predictive of significant response to educational intervention.

Master of Science in Medicine / Rationale: Asthma management aims to achieve optimal control on the minimal effective dose of medication. We assessed the effectiveness of two algorithms to guide ICS dose in well-controlled patients on ICS+LABA in a double-blind study, comparing dose adjustment guided by exhaled nitric oxide (eNO) to clinical care algorithm(CCA) based on symptoms and lung function. Methods: We randomised non-smoking adult asthmatics on minimum FP dose 100μgs daily +LABA to ICS adjustment using eNO or CCA, assessed over 5 visits during 8 months treatment. Primary endpoints were asthma-free days and asthma related quality of life (QOL). Analysis was by mixed model regression and generalised estimating equations with log link. Results: 69 subjects were randomised (eNO:34, CCA:35) and 58 completed the study. At baseline mean FEV1 was 94% pred., mean eNO (200ml/sec) 7.1 ppb, median ACQ6 score 0.33. Median ICS dose was 500 μg (IQR 100-500) at baseline and 100 μg on both eNO (IQR 100-200) and CCA arms (IQR 100–100) at end of study. There were no significant differences between eNO and CCA groups in asthma-free days (RR=0.92, 95% CI 0.8–1.01), AQL (RRAQL<median = 0.95, 95% CI 0.8–1.1) or exacerbation-free days (HR = 1.03, 95%CI 0.6–1.7). Neither clinic FEV1 (overall mean difference FEV1 % pred. -0.24%, 95% CI -2.2–1.7) nor a.m. PEF (mean difference 1.94 L/min (95% CI -2.9–6.8) were significantly different. Similar proportions of subjects were treated for ≥1 exacerbation (eNO: 50%, 95% CI 32.1–67.9; CCA: 60%, 95% CI 43.9–76.2). Conclusion: Substantial reductions in ICS doses were achieved in well controlled asthmatics on ICS+LABA, with no significant differences in outcomes between eNO or clinically based algorithms.

There are approximately 22.2 million Americans’ who are living with asthma and of those 18.4 million are adults. African Americans’ are more likely to be diagnosed with asthma compared to Caucasians, and experience more asthma attacks. In this study, the Social Cognitive Theory was used to examine the relationships among personal characteristics, environmental factors, asthma self-efficacy, self-management behaviors, and quality of life (QOL) in African American adults with asthma. A correlational design was used. Data were collected from a non-random sample of adult African Americans’ with asthma (N = 39) using the following self-report questionnaires: the Knowledge, Attitude, and Self-Efficacy of Asthma Questionnaire (KASE), the short form of the Rapid Estimate of Adult Literacy in Medicine (REALM-SF), the Medical Outcomes Study (MOS) for social support, the Asthma Trigger Inventory (ATI), the Morisky Medication Adherence Questionnaire, Asthma Self-Management Questionnaire (ASMQ), the Modified Pittsburgh Sleep Quality Index (PSQI), the Asthma Control Test (ACT), and the Asthma Quality of Life Standardized (AQLQ-S). Data analyses included descriptive statistics, Pearson Product correlations, and hierarchical multiple regression. On average, participants (N = 39) were middle aged (M = 55.9 ± 7.9) years, female (65%), did not smoke (87%), did not use a peak flow meter (PEFR) to self-manage their asthma (72%), and were obese (M = 34.06, SD = 10.78). Participants reported high confidence in asthma self-management; however, had low medication adherence and scores indicating uncontrolled asthma (M = 16.10, SD = 4.29). More than half (67%) of the participants reported poor sleep quality (PSQI). BMI and sleep quality accounted for significant variance (38%) in asthma QOL (F (2, 38) = 7.08, p = .001). Social support was an independent predictor of asthma self-efficacy (F (2, 38) = 5.65, p = .02). Better control of weight and asthma symptoms may improve sleep quality. Health care providers need to address the ongoing challenges of asthma self-management and monitor sleep quality. Encouraging the use of peak flow meters, which have been shown to improve self-management and asthma control, may result in better quality of life for African Americans’ with asthma.

Asthma affects over 2.2 million people in Australia. Asthma morbidity is increasing while mortality is decreasing. People with asthma experience shortness of breath as their airways narrow and become inflamed. After an episode of acute asthma many patients experience a relapse requiring further emergency department care. Numerous studies have been undertaken to identify the determinants of asthma morbidity and these studies have primarily used asthma oriented and co-morbidity scales such as anxiety and depression indices. Other studies in this area have indicated psychosocial factors such as coping, asthma attitudes and beliefs that may be linked to people with asthma who are non-compliant or adherent to treatment. Currently, there is no research available that has examined the link between general health promoting behaviours, an individual’s risk behaviour assessment and a brief asthma education encounter that is patient-centred. This study provides a description of the health promoting and risk taking behaviours of people who attend the emergency department with acute asthma. Secondly, it examines the effectiveness of patient-centred education compared with standard education. One hundred and forty-six people with acute asthma who attended the emergency departments of the Princess Alexandra and Mater Adult Public Hospitals were enrolled in this study. Participants self-reported health promoting and risk taking behaviours by completing the questionnaire that contained the Health Promoting Lifestyle Profile (HPLPII) and the Health Risk Appraisal (HRA) instruments. The Hospital Anxiety and Depression Scale (HADS) was also incorporated into the questionnaire to ascertain levels of anxiety and depression in this acute asthma group of people. The asthma education curriculum had the same topics for both the standard education and the patient-centred groups. However, the patient-centred group were able to prioritise the order of the topics according to their identified need. Secondly, the patient-centred group were asked two questions to ascertain the most important issue and asthma issue for them at that point in time. Both groups of participants were educated using the Asthma Foundation Leaflet “Asthma - Basic Facts” during the individual education session. There were 56% females and 44% males with a mean age (+SD) of 34 (13.8) years with 70.3% reported year 12 or above education and 49% of participants earned less that $20,000. Nearly half of the participants were admitted to a hospital ward following emergency department assessment and care. A large proportion of the participants had either moderate or severe asthma. The health behaviour findings from this study suggest people with acute asthma follow preventive health recommendations and safety guidelines more so than the wider community. However, they did not self-initiate home based health actions such as breast self-examination. At the time of attendance to the emergency department with acute asthma there were no statistical difference between the patient-centred education and standard format education groups for age, gender, education, income, asthma control and previous emergency department attendances. The patient-centred education group had fewer re-attendances in the four months after the education intervention when compared with prior emergency department attendances than the control group (p=0.057; p=0.486). In conclusion, people with acute asthma report undertaking a number of preventive health behaviours and actions according to national guidelines and safety recommendations. They report a lack of self-initiated home based health behaviours. Further research is required to investigate the impact on the National Asthma Council’s recommendations of the importance of asthma action plans on people who follow preventive health guidelines and who lack self-initiative abilities. In terms of asthma education, patient-centred education when compared to standard format education may be useful in reducing further emergency department attendances for acute asthma. More research is required to identify other key education issues for people with acute asthma.

Master of Science in Medicine / Rationale: Asthma management aims to achieve optimal control on the minimal effective dose of medication. We assessed the effectiveness of two algorithms to guide ICS dose in well-controlled patients on ICS+LABA in a double-blind study, comparing dose adjustment guided by exhaled nitric oxide (eNO) to clinical care algorithm(CCA) based on symptoms and lung function. Methods: We randomised non-smoking adult asthmatics on minimum FP dose 100μgs daily +LABA to ICS adjustment using eNO or CCA, assessed over 5 visits during 8 months treatment. Primary endpoints were asthma-free days and asthma related quality of life (QOL). Analysis was by mixed model regression and generalised estimating equations with log link. Results: 69 subjects were randomised (eNO:34, CCA:35) and 58 completed the study. At baseline mean FEV1 was 94% pred., mean eNO (200ml/sec) 7.1 ppb, median ACQ6 score 0.33. Median ICS dose was 500 μg (IQR 100-500) at baseline and 100 μg on both eNO (IQR 100-200) and CCA arms (IQR 100–100) at end of study. There were no significant differences between eNO and CCA groups in asthma-free days (RR=0.92, 95% CI 0.8–1.01), AQL (RRAQL<median = 0.95, 95% CI 0.8–1.1) or exacerbation-free days (HR = 1.03, 95%CI 0.6–1.7). Neither clinic FEV1 (overall mean difference FEV1 % pred. -0.24%, 95% CI -2.2–1.7) nor a.m. PEF (mean difference 1.94 L/min (95% CI -2.9–6.8) were significantly different. Similar proportions of subjects were treated for ≥1 exacerbation (eNO: 50%, 95% CI 32.1–67.9; CCA: 60%, 95% CI 43.9–76.2). Conclusion: Substantial reductions in ICS doses were achieved in well controlled asthmatics on ICS+LABA, with no significant differences in outcomes between eNO or clinically based algorithms.

Despite national guidelines, the management of difficult asthma remains suboptimal, and there may be opportunities for pharmacists to improve asthma outcomes. This six-month prospective, randomised, open study investigated the effects of pharmaceutical care across primary and secondary care on difficult asthma. Fifty-two patients attending a hospital difficult asthma clinic were randomised (1:1) to receive usual medical care (UC), or pharmacist interventions (PI) comprising asthma review, education, and medicines optimisation from a hospital advanced clinical pharmacist, plus follow-up targeted Medicines Use Review (t-MUR) from community pharmacists. Forty-seven patients completed the study. More interventions were performed in the PI group at baseline (total 79 vs. 34, p<0.001), but only six patients received a t-MUR. At six-months, PI were non-inferior to UC for all outcomes. The primary outcome measure was Juniper’s Asthma Control Questionnaire score and reduced (improved) from a median (IQ) score of 2.86 (2.25, 3.25) and 3.00 (1.96, 3.71) in the PI and UC groups respectively to 2.57 (1.75, 3.67) and 2.29 (1.50, 3.50). At baseline, 58.8%, 46.9% and 17.6% of patients had optimal inhaler technique using Accuhalers, Turbohalers or pMDIs; education improved technique but this was not maintained at six-months. Adherence rates < 80% were observed in 57.5% of patients at baseline, and was improved in the PI group at six-months (10/20 PI vs. 3/21 UC had adherence rates of 80-120%, p=0.020). This study demonstrates that the management of difficult asthma by specialist pharmacists is as effective as usual medical care. Future research should investigate whether pharmacist-led follow-up produces further improvements.