State of the Science Congress on Nursing Research September 14, 2012

1. The Effects of Coping Skills Training in Low-Income Urban African-American Adolescents with Asthma State of the Science Congress on Nursing Research September 14, 2012

2. The Effects of Coping Skills Training in Low-Income Urban African-American Adolescents with Asthma Principal Investigator Barbara Velsor-Friedrich PhD, RN Co-PI’s Maryse Richards, PhD Jerold Sterling MD, FAAP Gary Sigman MD Fred Bryant, PhD Project Manager Lisa Militello MPH, MSN, CPNP

3. The Effects of Coping Skills Training in Low-Income Urban African-American Adolescents with Asthma Research Assistants Regina Conway-Phillips Israel Gross Edna Romero Patrick Harrison Provost Scholars Lauren Wedel Maria Smith Undergraduate Assistant Amanda Stoltz

4. T.E.A.M.

5. Conflict of Interest • This educational activity is presented without the provision of commercial support and without bias or conflict of interest from the planners and presenters

6. Significance • There are approximately 7 million U.S. youth under the age of 17 years who have been diagnosed with asthma.

7. Significance • Approximately 19% of all U.S. high school students have been diagnosed with asthma at some point in their lives. • Approximately 14 million school days are lost per year. • Health care and lost productivity costs are estimated at $14.2 billion/year.

8. Significance • Asthma disproportionately effects minority populations. • Adolescents are particularly at risk for poor control of this life-threatening disease.

9. Significance • Exacerbations of asthma can be affected by psychosocial stress that is often associated with social conditions of poverty and neighborhood stress. • Coping strategies may counteract some of the negative outcomes associated with stress.

10. Purpose • To evaluate the efficacy of a school-based program TEAM (Teen Educational Asthma Management) on asthma self-care, asthma related quality of life, asthma knowledge, asthma self-efficacy, coping, and asthma health outcomes (FEV1, mean peak flow reading, symptom days, asthma related ED visits, hospitalizations & school absences).

11. TEAM Program • 1) Baseline Physical with a Nurse Practitioner & Development of Individual Asthma Action Plan • 2) Two Asthma Education Sessions • 3) Five Coping Skills Training Sessions + one booster session (treatment group only). • 4) Four Nurse Practitioner Follow-Up Visits • Students in both groups were compared at three posttest times: 2, 6, and 12 months.

12. Coping Skills Training • A cognitive behavior strategy that teaches students personal and social coping skills to assist in making health related decisions. • Skills taught include: problem-solving, effective communication, stress management, cognitive restructuring, and conflict resolution.

13. Problem Solving • Alternative ways of dealing with situations and potential consequences of those alternatives; choose a method and evaluate outcomes.

14. Effective Communication • Help participants express themselves in ways that are clear, appropriate and constructive. • Review forms of communication. • Discuss guidelines for speaking and listening.

15. Managing Stress • Teach a variety of stress management techniques (deep breathing, muscle relaxation & guided imagery).

16. Cognitive Restructuring • Recognition of thoughts and feelings • Changing negative thoughts into positive thoughts (self-talk)

17. Conflict Resolution • Focuses on reassessing conflict situations with the goal of finding a “win-win” resolution.

18. Coping Skills Training • First the aspects of the skills are taught • Then an asthma-health scenario is described where the skill can be used • Participants are asked to describe how the skill can be implemented in the asthma scenario • Participants are asked to practice the skill that week • The next sessions starts with an update of their use of the skill and any questions

19. Recruitment • Fliers were posted around the schools • School based NP assisted in recruitment • TEAM recruitment table during student orientation and report card pick up days

20. Sample • A total of 137 African-American low-income urban teens with intermittent or persistent asthma were enrolled in the study over a four year period. • All students attended urban high schools with school-based health centers (SBHC).

21. CPS Student Deaths

22. VIOLENCE Chicago Teen Violence A High School student wears a jacket with a long list of names of people who have died, as he heads into school. Following the slaying of a student earlier this month, community leaders, parents and police gathered for "Operation Safe Passage," an effort to encourage school attendance by acting as escorts for the students as they travel to and from school. (AP Photo/The Tribune, Nancy Stone)

23. CPS Public High School

24. Student Participants

25. Instruments • Parent Asthma Questionnaire • Asthma Self-Care • Asthma Quality of Life • Asthma Knowledge • Asthma Self-Efficacy • Kid Cope • Asthma Health Outcomes (FEV1, PEFR, symptom days, ED visits/hospitalizations & school absences)

26. Baseline • Mean Age = 15.5 years. Range = 13 – 18 • Gender = Females 65% and Males 35% • Asthma QOL scores indicated a moderate level of impairment for all students • Only 53% of students were determined to be in control of their asthma.

27. Analyses • Data was entered, checked and cleaned. • Missing data was imputed via the maximization likelihood method • Using an intent to treat approach, mixed model ANOVAs were used to analyze the data.

28. Findings • Both groups improved over time, with significant increases in: • Asthma related-qol (p < .05) • Asthma knowledge (p < .01) • Asthma self-efficacy (p < .001) Significant Decreases in: • Symptom days (p < .001) • School Absences (P < .001)

29. Findings However, there were no significant differences between groups on any of the outcome variables. • In the intervention group, increased treatment dosage was significantly associated with decreased asthma symptoms (p = .05) and marginally associated with increased asthma self-care (p = .07). • The intervention was most effective among participants reporting poorer asthma control.

30. Limitations • Students with persistent asthma were more difficult to recruit as they often had other school issues that kept them out of school. • Level of attention control received by both groups may have impacted the findings.

31. Limitations High mobility rates, competing academic or school-related events and violence often interfered with the routine delivery of the program. 75% of students attended 4/5 (80%) of the CST sessions.

32. T.E.A.M Student Letter

33. Implications • The findings of this study highlight the utilization of an innovative education program for vulnerable African-American teens with asthma. The use of a group-based intervention delivered in the school setting was beneficial for low-income minority teens with asthma.

34. Funding • This study is funded by the National Institute of Nursing Research RO1 NR950202.

35. What’s Next? • ICAN (I Can Control Asthma and Nutrition Now) pilot completed this past fall. • Asthma Education • Nutrition Education integrated with CST • Parent Session • Re-enforcement visits with the NP and Dietitic Interns