Research language?! Homework help. =(

[jenannebeard]

I'm so confused with reasearch language! What is this question actually asking me to find in this article?

1. Is a theoretical/conceptual framework specified? And what is it?

I'm having a hard to identify it.

The article is lengthy so I apologize but obviously you don't have to read the whole thing. I know once I find it I'll be able to move on to answering my other questions correctly. I just need some help with identifying it.

Thanks for your help!

Impoverished children with asthma: a pilot study of urban healthcare access.

By Klinnert, Mary

Publication: Journal for Specialists in Pediatric Nursing

Thursday, April 1 2004

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ISSUES AND PURPOSE. Using Andersen's Behavioral Model of Health Care Use, this pilot study was conducted to better understand the experiences of children with asthma as they access an urban healthcare system.

DESIGN AND METHODS. This descriptive study used a convenience sample of 34 families of pediatric asthma patients who participated in semistructured interviews and closed medical record review.

RESULTS. Only one patient reported having a written exacerbation management plan. Beliefs regarding medication addiction and side effects were frequently reported as barriers to medication adherence, and children seeking asthma care in primary care settings saw many care providers.

PRACTICE IMPLICATIONS. Exploring how expanded nursing roles can help address both family and system factors serving as barriers to health care ought to be a key priority for nursing.

Search terms: Accessibility, asthma, health beliefs, health services

**********

Asthma is the most common childhood illness and, despite advances in asthma management, morbidity and mortality rates are rising (Centers for Disease Control and Prevention, 1998; Tartasky, 1999). Latest estimates project asthma expenditures of at least $12.7 billion annually (Public Health Policy Advisory Board, 2002). Many factors seem to contribute to asthma morbidly, including race and ethnicity, socioeconomic status, urban dwelling, severe disease, prior emergency room visits, psychological problems, and treatment nonadherence. Urban, impoverished, minority children contribute disproportionately to the trend of increasing asthma morbidity and mortality (Aligne, Auinger, Byrd, & Weitzman, 2000; Bartlett et al., 2001; Miller, 2000).

Urban impoverished children with asthma, regardless of payor source, access costly emergency services more frequently than do their nonurban counterparts (Halfron & Newacheck, 1993; Lozano, Connell, & Koepsell, 1995; Ortega et al., 2001). Children with Medicaid are likely to report a usual source of routine care but are less likely to receive care in a primary care office or to have continuity between care sources (Crain, Kercsmer, Weiss, Mitchell, & Lynn, 1998; Halfron & Newacheck; Kattan et al., 1997). In a recent study, 75.4% of parents of urban asthmatic children cited the emergency department (ED) as their usual source of care (Crain et al.). This reliance on emergency care services appears to play a role in rising asthma morbidity among urban children because those frequently accessing emergency care also have fewer visits to primary care providers and are less likely to fill prescriptions for inhaled anti-inflammatories (Ortega et al.). Having previous emergency room visits for asthma care also is a predictor of more emergency room visits in the future (Emerman, Cydulka, & Rim, 1999; Wasilewski et al., 1996).

Conceptual Framework

Andersen's Behavioral Model of Health Services Use well-established framework for understanding the determinants of healthcare access (Aday & Andersen, 1974; Andersen, 1995) and continues to be a relevant and evolving model in health services research. The model "provides a framework to describe those factors that inhibit or facilitate entrance to the health care delivery system as well as ... how these inhibiting (and facilitating) factors operate to affect admittance" (Aday, Andersen, & Fleming, 1980, p. 36). Andersen's model lends structure to the concept of healthcare utilization by identifying and organizing the characteristics involved in how individuals access resources. The model suggests culture, social structure, individual characteristics, healthcare system organization, and need for services influence individual healthcare utilization (Aday & Andersen; Andersen). Andersen's predisposing and enabling attributes appear to have particular significance for urban children with asthma. Key elements specific to Anderson's model are presented in Figure 1.

[FIGURE 1 OMITTED]

Predisposing Attributes

In Andersen's model, demographics, social structure, health beliefs, and psychosocial characteristics predispose a person's access to care (Andersen, 1995).

Among children with Medicaid, race and ethnicity are associated with higher resource utilization for asthma (Apter et al., 1997; Joseph, Havstad, Ownby, Johnson, & Tilley, 1998; Liu et al., 2000). This is also evident in a managed care setting in which African-American patients filled controller medications, such as inhaled anti-inflammatory agents, less frequently than their white counterparts did (Zoratti et al., 1998). Increases in hospitalization rates appear to be associated with greater numbers of nonwhite residents and lower levels of education (Gottlieb, Beiser, & O'Connor, 1995); however, rates of ED use do not decline with increased income for African-American children (Miller, 2000).

The mental health of children and caretakers, as well as family functional status, are predictive factors in asthma morbidity (Bartlett et al., 2001; Klinnert, McQuaid, & Gavin, 1997; Weil et al., 1999). Caregiver problem-solving skills and positive expectations are associated with higher functional status among urban children with asthma (Wade, Holden, Lynn, Mitchell, & Ewart, 2000). Asthma itself does not appear to expose children or caretakers to increased risk of mental health difficulties (Bender et al., 2000).

Many studies suggest urban children underutilize efficacious inhaled anti-inflammatory agents (Butz, Eggleston, Huss, Kolodner, & Rand, 2000; Diaz et al., 2000; Warman, Silver, McCourt, & Stein, 1999). A lack of caretaker confidence in asthma medications is linked to ED visits (Wasilewski et al., 1996), suggesting medication beliefs play a part in morbidity and utilization. Mansour, Lanphear, and DeWitt (2000) found that health beliefs inherent to urban caretakers, such as competing demands and prioritization, serve as significant barriers to asthma care.

Enabling Attributes

Enabling attributes are those resources allowing individuals to access the healthcare system. Simply possessing health insurance and knowing where to obtain health services do not determine healthcare access for urban children with asthma (Mansour et al., 2000). Lack of understanding about asthma medications, exacerbation management, and decision-making skills regarding emergency care access may be evidence of ineffective family education by urban care providers (Warman et al., 1999; Wasilewski et al., 1996). The availability of appropriate care delivered by urban providers is an enabling characteristic according to Andersen's model. Despite the availability of evidence-based guidelines, healthcare providers do not consistently administer evidence-based care to urban children (Diaz et al., 2000; Taylor, Auble, Calhoun, & Mosesso, 1999). They do not prescribe inhaled anti-inflammatory agents appropriately, do not provide effective medication information, and inconsistently provide exacerbation management plans outlining asthma medications, asthma symptoms, and what parents should do during an asthma exacerbation (Hartert, Windom, Peebles, Freidhoff, & Togias, 1996). Table 1 shows readily available resources for asthma management plans and guidelines.

While some studies have investigated the urban asthma "epidemic" in terms of characteristics found in individual families and access barriers, few have subjectively compared data given by families against medical record review. Additional research is needed to assess family beliefs about asthma, sources of asthma disease knowledge deficits, and ineffective aspects of healthcare provided to this population in order to understand how each affects urban asthma morbidity among impoverished children. The purpose of this descriptive study, using a behavioral model of healthcare use, is to explore the asthma care provided to urban children.

Methods

A descriptive study was conducted in an integrated urban healthcare system. Consenting patients participated in an interview assessing beliefs and knowledge along with current exacerbation management practices. A closed medical record review exploring the number of primary care providers involved in asthma management, prescribed medications, emergency visits, and hospitalizations also was used to assess care quality and resource utilization. The study was approved by the University of Colorado Institutional Review Board for human subject research.

The registered nurse (RN) case manager interviewed patients and families referred by physicians and nurses working in the urgent care clinic, intensive care unit, inpatient unit, and a community clinic over a 1-year period. Included were families of children up to 18 years of age with a diagnosis of asthma who had at least one previous urgent care contact and/or hospital admission for asthma. Non-English-speaking families were excluded.

Family Knowledge and Management

The Family Asthma Management Symptom Scale (FAMSS), developed to evaluate the complex nature of family asthma management and shown to have good reliability and validity measures (Klinnert & Bender, 2002; Klinnert et al., 1997), was adapted and used by the RN case manager. The 40-minute FAMSS interview was shortened to a 20-minute format in order to conduct the interview during limited clinical time. National Inner-City Asthma Study questions were added (Mitchell et al., 1997) to assess asthma medication barriers and beliefs. The interview was examined for content validity by an expert asthma researcher. The psychometrics of the adapted tool were not measured due to the descriptive, exploratory nature of the study. Table 2 shows sample interview questions. The RN case manager used predetermined criteria to judge written transcripts for elements associated with successful asthma management including general asthma knowledge, symptom perception, symptom response, primary care provider (PCP) planning, environmental control, medication compliance, and adherence complications.

Utilization and Access

Medical record review examined inhaled steroid prescription rates and asthma specialty clinic use. Data were collected reflecting utilization of acute care, emergency care, and asthma-related primary care services. The number of PCPs involved in asthma care also was considered.

Results

Sample Characteristics

Thirty-five children in 34 families participated for 1 year. According to current National Heart Lung and Blood Institute guidelines (National Institutes of Health, 2002), all 35 participants met criteria for persistent asthma. The average age was 7.9 years (range 18 months to 16 years). Twelve children were female (34%). Eight children (23%) were African American, 21 (60%) Hispanic, and 6 (17%) white (non-Hispanic). Of those reporting, 21 (62%) mothers were single, 8 (24%) were married, and 4 (12%) were grandmothers who served as guardians. The children had a mean 34.2 (0-75) months of asthma management records in the healthcare system. Twenty-eight percent of participants had no insurance coverage, while Medicaid HMO covered 26% and Medicaid covered 23%. Ten percent had S-CHIP, 10% had private insurance, and 3% were covered by an indigent care grant.

Family Knowledge and Management

Interview results indicated that, although many parents (82%) included "difficulties with breathing" in their definition of asthma, fewer (58%) freely associated the lungs with their definition of asthma. Most parents and children (97%) could identify at least one symptom indicating an asthma exacerbation, most often coughing and wheezing, but fewer (36%) could name signs of an impending exacerbation. Only 64% could distinguish between severe exacerbation symptoms and less severe symptoms. Retractions, posturing, and lethargy were listed as symptoms parents first recognized. Many (76%) identified a seasonal asthma symptom pattern; however, fewer (55%) identified a daily symptom pattern to their child's asthma.

Most families (76%) could name symptoms requiring treatment, but fewer (12%) could name symptoms, such as onset of a cold or exposure to environmental triggers, requiring proactive treatment. With asthma exacerbations, 55% of families did not include assessment of the child's condition, 58% did not identify symptoms necessitating emergency treatment, and 88% did not identify symptoms necessitating contact with their primary care providers. Only one family indicated it had a written plan outlining home asthma care. Most families had a nebulizer (91%) and medications (73%) at home, and most parents could name their children's medications (73%).

Questions targeting asthma medication beliefs suggest the majority of families believe beta-agonists (90%) and oral steroids (90%) help asthma. However, of those prescribed inhaled steroids, 29% believed they did not help or were unsure about efficacy. Several parents (26%) stated cost was a barrier to providing asthma medications, 35% expressed fear of medication addiction, and 42% expressed fear of medication side effects. Parents did not prefer alternative treatments, or feared giving the incorrect dose (4%). Some families indicated as reasons for nonadherence a lack of availability of asthma medications at the pharmacy (19%), a lack of transportation to the pharmacy (19%), difficulty following the medication schedule (13%), and the desire to stop medication before the prescription was finished (16%). However, more parents indicated that difficulty giving medications (42%) and not having the medication at home when needed (45%) were more likely reasons for not giving asthma medications.

Utilization and Access

Sixty percent of patients were prescribed an inhaled steroid, and 43% had consulted with a pediatric allergist. Children were likely to see multiple providers in community clinics for asthma care. The number of providers correlates to both number of visits made to community health clinics for asthma care ([r.sub.s] = 0.741, p [less than or equal to] 0.05) and with the length of time children are enrolled in the system ([r.sub.s] = 0.561, p

Discussion

Episodic asthma care and low level of medication adherence by urban children with asthma has been reported. We observed in our cohort of children with persistent asthma that significant deficits exist in disease understanding and care management. Only one patient reported having a written exacerbation management plan. Beliefs regarding medication addiction and side effects were frequently reported as barriers to medication adherence. Children seeking asthma care in primary care settings are likely to see multiple care providers. This appears to be related to poor problem solving around asthma exacerbations. These results indicate that family and system factors--or predisposing and enabling attributes--appear to serve as access barriers for these urban children with asthma.

Exacerbation Management

Inadequate caretaker understanding regarding exacerbation management is a factor in increased utilization (Warman et al., 1999), and our results are similar in this regard. Parents denied having written exacerbation management plans, an issue noted by others (Yoos et al., 1997) and a factor in increased ED use (Wasilewski et al., 1996). According to Andersen's model, education regarding what to do and where to go during an asthma exacerbation would be a factor enabling a person to appropriately access healthcare services. The lack of exacerbation management information may increase this population's use of emergency resources.

Medication Beliefs

Low caretaker confidence in asthma medications is a risk factor for ED use (Wasilewski et al., 1996). One recent study found that health beliefs and other social stressors intrinsic to urban caretakers were found to be more significant barriers to asthma care than were availability of services, cost, or insurance status (Mansour et al., 2000). Our results also suggest that beliefs inherent to urban caregivers, or predisposing attributes, may be equally important as cost barriers. Past research has repeatedly reported a low level of adherence with asthma medication regimens, particularly in urban populations (Butz et al., 2000; Diaz et al., 2000; Warman et al., 1999).

Lack of understanding about the use of inhaled steroids during asymptomatic periods may contribute to their underuse, but concern about side effects is a commonly cited reason for nonadherence (Chambers, Markson, Diamond, Lasch, & Berger, 1999). Although the uninsured composed the largest percent of study participants (28%), we found that many families named a fear of side effects and addiction as reasons for potential non-adherence. A lack of education targeting beliefs about medications and the persistence of asthma may have an impact on how children with asthma living in urban poverty access services differently. In addition, the role of Andersen's predisposing and enabling attributes in access to healthcare services, or the hypothesis of a link among medication beliefs, misinformation, misuse, and resource utilization, appears to be supported by findings in this study.

Continuity of Care

Children seeking primary care appear to experience a lack of continuity, with its associated use of emergency services and hospitalizations (Christakis, Mell, Koepsell, Zimmerman, & Connell, 2001). Children receiving asthma care by a PCP who could be reached by telephone, who had received a written asthma plan (Warman et al., 2001), and who perceive themselves as active participants in their care management (Chambers et al., 1999) are more likely to use controller therapy. Focus group interviews of urban minority caretakers suggest the theme of inconsistent care and messages given by providers is important (Yoos et al., 1997). For our sample, the healthcare system, poised to act as an enabling attribute to appropriately accessing healthcare services, may instead be contributing to these children's reliance on emergency services.

Limitations and Implications

This study's small sample size and exclusion of monolingual Spanish-speaking participants are limitations. However, results suggest the need for further research into how beliefs and system factors affect use of primary care and medication adherence. How the characteristics of urban healthcare systems affect quality patient care should be considered when creating consistent, quality health-education programs. Studies incorporating larger samples that circumvent language barriers may better investigate the reasons for urban children to suffer a disparate asthma burden. Expanded nursing roles, such as case management and health educators offering continuity and comprehensive teaching, may help better serve impoverished urban children with asthma.

Table 1. Asthma Resources The following Web sites provide information on asthma management guidelines and exacerbation management guidelines: nationaljewish.org / pdf / asthma_action_plan.pdf http://www.nhlbi.nih.gov / guidelines / asthma / asthgdln.htm http://www.aaaai.org / members / resources / initiatives / pediatricasthma.stm Table 2. Sample Questions From Semistructured Interview * Tell me your understanding of what asthma is. * How do you tell your child is having breathing problems? * What things cause your child to wheeze? * Tell me, step-by-step, using as much detail as you can, what you do when your child has trouble with his/her asthma. * What has your doctor told you to do if your child has an asthma attack? Has a plan ever been written out for you? * Can you tell me the names and doses of your child's medications? * When does your child have the most trouble with his/her asthma? Is there a time of year or a time of day? * Do you think oral steroids (give example of medication) help your child's breathing problems? * Do you think inhaled steroids (give example of medication) help your child's breathing problems? * People have many reasons why they might not be able to give their child his/her asthma medicines. Can you tell me if any of the following have caused you not to be able to give your child his/her asthma medicines? --Hard to get to the pharmacy --Medicines cost too much --Ran out or wasn't prepared --Afraid of child becoming addicted --Side effects --Use alternative treatment --Trouble getting child to take medication --Afraid of wrong dosage --Schedule or prescription hard to follow

[mt3]

Seems like the answer is given in the article.

"Conceptual Framework

Andersen's Behavioral Model of Health Services Use well-established framework for understanding the determinants of healthcare access (Aday & Andersen, 1974; Andersen, 1995) and continues to be a relevant and evolving model in health services research. The model "provides a framework"

[classicdame, MSN, EdD]

Conceptual frameworks involve various concepts that have been defined and make up the "frame" for the topic you are covering. For instance, advocate, professional, caring, etc are all concepts of a nurse. If you use a conceptual framework you must define all the concepts related to the topic, or find an article where that has been done. A theory may be based on concepts but has been measured and defined. A theory ought to be something you can replicate and get the same results (has validity).

[Rob72, ASN, RN]

1. Is a theoretical/conceptual framework specified? And what is it?

How are they defining or analyzing the topic, what tools are they using?

Research publications follow basically the same pathways:

• ISSUES AND PURPOSE- What they looking at/for, and why it is important.
  
• DESIGN AND METHODS. The type of study that was done and what "tools" were used. Is it randomized, placebo-controlled, retrospective, structured/semi-structured interview...?
  
• RESULTS- What did we find out/decide.
  
• PRACTICE IMPLICATIONS- Or, simply, "Implications". How do the results suggest procedures or techniques should be changed?
  

The qusetions to ask when reviewing any research topic are:

• Why did they examine this particular population?(I.e., in a study of social function among pot-heads, do we evaluate everyone who lives in Momma's basement and has Momma paying the bills, or do we evaluate only those who are self-sustaining?)
  
• Did they exclude other populations, or parts of the population, that could have changed the findings? (I.e., Avandia has been linked to coronary sequelae among diabetics. Is there statistical significance, or is it simply that older diabetics predominantly have CAD?)
  
• Were the design and methods the best way to gather data? How reliable was this study? (I.e., self-reporting among illicit drug users, vs. gathering a de-identified UDS/SDS )
  

[kakamegamama]

Your answer is in the article. Just read again and think. Bounce your answer off of your professor--that's one of the reasons he/she is there.