The Journal of School Nursing
© The Author(s) 2020
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DOI: 10.1177/1059840520934178
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2022, Vol. 38(4) 347–357
Children with chronic conditions (i.e., asthma) are more likely to have anxiety or depressive symptoms. Comorbid asthma and anxiety in children leads to increased morbidity, causing children to miss instructional time and parent/caregiver (CG) work absences. Asthma educational programs and mental health interventions have been developed, though no scalable programs integrate asthma education and mental health behavioral interventions for school-aged children. This study evaluated the sustained preliminary effects of an integrated asthma education and cognitive behavioral skills-building program, Creating Opportunities for Personal Empowerment for Asthma. Thirty-two children ages 8–12 years with asthma and symptoms of anxiety received the intervention. At 6-weeks postintervention, anxiety and CG-reported behavioral symptoms were significantly reduced, there were fewer missed doses of asthma controller medications, and asthma-related self-efficacy, personal beliefs, and the children’s understanding of asthma significantly increased. Most children (n = 29, 91%) reported continued use of coping skills.
Keywords
childhood asthma, anxiety, school-based intervention, cognitive behavioral skills-building, school nursing
Children with chronic conditions, such as asthma, are more likely to have anxiety or depressive symptoms (Goodwin et al., 2013) as well as mental health issues in general (Adams et al., 2017) Specifically, children with asthma can have more than 3 times the risk of an anxiety disorder than those without asthma (Dudeney et al., 2017). Children with comorbid asthma and anxiety/depression tend to have poorly controlled asthma and incur more emergency department/urgent care visits than children with asthma but without anxiety or depression (Goodwin et al., 2013). A meta-analysis of adolescents with asthma indicated similar findings (Lu et al., 2012). Children with comorbid asthma and anxiety/depressive symptoms also tend to have a lower quality of life (QOL) and higher morbidity and mortality rates (Feldman et al., 2005; Goodwin et al., 2013; Lu et al., 2012; Strunk et al., 1985) contributing to missed instructional time in school for the child and missed work for the parents/caregivers (CGs). Even more concerning is that asthma-related health outcomes are worse for children among racial/ethnic minorities, particularly of Black and Puerto Rican descent, and those from socioeconomically disadvantaged homes (Bignall et al., 2015; Centers for Disease Control and Prevention, 2019; Chen et al., 2016; Shams et al., 2018). Unfortunately, children from these higher risk groups (i.e., socioeconomic disadvantage and racial/ethnic minority) are less likely to obtain mental health services when diagnosed with a psychological condition (Akinbami et al., 2016; Avenevoli et al., 2015).
Symptoms of anxiety can be misinterpreted as asthma (Goodwin et al., 2013), and common asthma symptoms such as coughing and wheezing are frequently ignored by youth (Mammen et al., 2017). Additionally, the risk of death from asthma increases during adolescence and young adulthood (S. L. Murphy et al., 2017). As such, interventions to improve accurate asthma symptom perception, asthma education, and coping skills training to address anxiety and depression are imperative. Previous studies have called for more rigorous and scalable interventions for children with asthma and comorbid symptoms of anxiety/depression, yet no evidence-based interventions for this population were found in a review of the literature (Al Aloola et al., 2014; Lu et al., 2012; Ritz et al., 2013).
The conceptual framework for this study integrates two theories, the common sense model (CSM) of self-regulation (previously known as the CSM of illness representations; Leventhal et al., 2016) combined with cognitive theory (CT; Beck & Beck, 2011). The CSM was developed for individuals with chronic conditions and purports that people develop concurrent cognitive and emotional representations of their illness; coping procedures and evaluation of actions taken that contribute to how the illness is conceptualized (Leventhal et al., 2016). The basis of CT is that one’s thoughts impact their feelings and behaviors (Beck & Beck, 2011). Both theories have separately guided interventions for adults and children with chronic conditions and mental health issues (Arnberg & Öst, 2014; Hickman et al., 2015; Hudson et al., 2015; Law et al., 2014), but no known interventions or studies have integrated both theories even though they complement each other. Because children with asthma and anxiety or depressive symptoms have increased morbidity (Goodwin et al., 2013), this population may benefit from an intervention that combines both by addressing their understanding of asthma and learning coping skills to address their mental and physical health.
The purpose of this study was to evaluate the sustained preliminary effects of an integrated asthma education and cognitive behavioral skills-building program, Creating Opportunities for Personal Empowerment (COPE) for Asthma. The feasibility, acceptability, and pretest/immediate posttest results of the COPE for Asthma program were previously reported.
The design for this study was a one-group pretest, posttest design with a 6-week postintervention follow-up assessment. A single group design was chosen for this feasibility pilot study because the COPE for Asthma intervention was newly adapted for 8- to 12-year-old children with asthma and symptoms of anxiety/depression in an urban setting. The COPE for Asthma research protocol was approved by The Ohio State University’s Institutional Review Board (IRB) and the Columbus City Schools Research Committee.
The intervention sessions were delivered in each school in a designated room for each group/school (i.e., conference room or art room) weekly as “lunch-bunch” groups. The groups were separated by grade blocks: second and third grades had the first lunch, and fourth to sixth grades were in the second lunch period. This was an appropriate separation given the developmental differences of each group.
“Fast passes” were provided for students in the COPE for Asthma groups to maximize the group time for the content to be covered. The intention was for the participants to go to the front of the lunch line, retrieve their lunches, and walk to the intervention room. The interventionist explained the rationale of the fast passes to the teachers and the cafeteria workers at each school.
A convenience sample of 32 elementary students and their primary CGs were enrolled. The sample size was midrange for typical pilot studies, which range from 20 to 40 participants (Hertzog, 2008). The sample size also allowed for a conservative estimate of 20% attrition (Melnyk & Morrison-Beedy, 2018).
Children were eligible if (a) 8–12 years of age in Columbus City Schools, (b) previously diagnosed with asthma, (c) they had elevated scores for anxiety (Screen for Child Anxiety Related Disorders [SCARED]; Birmaher et al., 1999; Hale et al., 2011) or depressive symptoms (Patient-Reported Outcomes Measurement Information System (PROMIS)—Child Depression Short Form; Assessment Center, 2015) measure, (d) they had written consent to participate from their CG and provided assent for themselves, (e) the consenting CG cared for the child at least half of the time, (f) CG and child could understand/were fluent in English. Exclusion criteria were as follows: (a) child had other respiratory or lung conditions, (b) the child was seeing a behavioral health care provider, or (c) child or CG had a cognitive learning limitation precluding either to complete surveys.
Pediatric symptom checklist (PSC-17). The PSC is used to assess behavioral and attention problems in children, α = .89 (J. M. Murphy et al., 2016). The PSC has 17 questions rated from 0 to 2 (never to often, respectively) and includes items such as “My child worries a lot” and “My child is down on self.” Higher scores indicate more behavioral symptoms reported by the CG.
Anxiety measure (SCARED). The SCARED (41 items; scored 0–2; not true to very true, respectively) is used to assess constructs including panic/somatic, general anxiety disorder, separation anxiety, social phobia, and school phobia. Questions include “When I am frightened, it is hard to breathe” and “I am afraid to be alone in the house.” Higher scores indicate more symptoms of anxiety (α = .70–.90; (Beidas et al., 2015; Birmaher et al., 1999; Hale et al., 2011).
Depression measure (PROMIS—child depression short form). The PROMIS Child Depression Short Form is used to evaluate mood, affect, and views of self. The measure has 8 items and is scored from 0 to 4 (never to almost always, respectively) and includes questions such as “Over the past week, I could not stop feeling sad” and “Over the past week, it was hard for me to have fun” (α = .85; Assessment Center, 2015).
Personal beliefs: Child version. The personal beliefs measure is used to assess beliefs and confidence about stress management. The measure has 10 items including “I am sure that I can handle my problems well” and “I know how to deal with things in a healthy way that bother me.” Scoring is from 1 to 5 (strongly disagree to strongly agree, respectively) with higher scores indicating higher general self-efficacy (α = .85; Jacobson & Melnyk, 2012).
Asthma illness representations–child version (AIRS-C). The AIRS-C is a 17-item scale that is used to identify barriers to and risk factors for lack of adherence to asthma controller medication, α = .85 (Sidora-Arcoleo et al., 2010). Scoring for items is 1–5 (i.e., strongly agree to strongly disagree, respectively). Sample questions are “There is little I can do to control my asthma symptoms” and “Tobacco smoke can make an asthma episode worse.” Higher scores indicate more congruence with the professional model of asthma and asthma management.
Child asthma self-efficacy (CASE). The CASE is a 14-item measure, scored from 1 to 5 (not at all sure to completely sure) and is used to assess children’s beliefs about managing asthma and evaluates symptoms of asthma, their health, and the effect of the child’s asthma on the family. The CASE includes items such as “How sure are you that you can learn the skills you need to control your asthma?” and “How sure are you that you can avoid things you are allergic to?” Higher scores are equivalent to higher asthma-related self-efficacy, α = .87 (Bursch et al., 1999).
Pediatric asthma quality of life questionnaire (PAQLQ). The PAQLQ is a 13-item questionnaire used to measure and evaluate problems related to asthma such as symptoms, activity limitations, and emotions. Items are scored from 1 to 7 (extremely bothered to not bothered) and include questions such as “I feel different or left out because of my asthma” and “I felt tired because of my asthma.” Higher scores indicate a higher QOL and a change in score of 0.5 is considered clinically meaningful, α = .8 (Juniper et al., 1993; Mahabaleshwarkar et al., 2016).
Child asthma symptom checklist (CASCL). The CASCL has 20- items and is used to measure how often children experience physical symptoms, irritability, and panic-fear during asthma attacks. The checklist includes items such as “During an asthma attack, I had coughing” or “I felt tired” and is measured from 1 to 5 (never to always, α = .81; Fritz & Overholser, 1989). Lower scores indicate fewer symptoms.
Child asthma control test (C-ACT). The C-ACT includes questions for children (four questions) and CGs (three questions) and measures interference with activities, asthma symptoms, and sleep disruption. The C-ACT items are measured from 0 to 3 (very bad/It is a big problem to very good/It is not a problem) and includes items such as “How is your asthma today” with higher scores indicating better asthma control. A cut-off score >19 is reflective of well-controlled asthma, α = .79 (Liu et al., 2007, 2010).
Data collection time points were at baseline, immediate postintervention, and 6-weeks postintervention. A research associate assisted/collected the data from the child participants in a small group format at each time point. Surveys by the CGs were completed in person or were sent home with the participating child and returned in a sealed envelope.
Quantitative analyses were completed using the Statistical Package for the Social Sciences, Version 24 (SPSS; IBM Corp., Released 2016). Repeated measures analysis of variance (RM-ANOVA) was conducted which allows for examination of individuals over time on the outcome variables, assumes that data are missing at random, and that dependent variable scores are correlated with measures from earlier assessments (Wang & Bodner, 2007). The time scores for the slope growth factor were fixed to 0, 1, and 2 (Muthén & Muthén, 2012). Bonferroni correction was used because of the multiple comparisons and to reduce the potential for a Type I error (Polit, 2010).
Effect size describes the magnitude, or how much, a variable impacts the independent variable (e.g., how much the intervention helped with symptoms of anxiety/depression/self-efficacy; McLeod, 2019; Polit, 2010). For this study, effect sizes for continuous variables were computed. The effect size used for RM-ANOVA in this study was partial Eta squared . Partial Eta squared is equivalent to Eta squared (η2 ) when used with a one-way RM-ANOVA (Levine & Hullett, 2002). Eta squared (and partial Eta squared in this case) effect sizes are .01, .06, and .14 (i.e., small, medium, and large, respectively; Polit, 2010).
Sphericity was assessed by examining Mauchly’s test. If Mauchly’s was significant, the F value was at risk of a Type I error. Greenhouse–Geisser was used as the correction in these cases. The tests of significance were set at .10 instead of .05 because of the small pilot study sample size to avoid making Type 2 errors (Polit, 2010; Wasserstein & Lazar, 2016).
Cronbach’s α coefficients were computed for each measure even though there was not a sufficient sample size to yield stable estimates (Kline, 2015; Polit, 2010) to get a general assessment of reliability.
COPE for Asthma was adapted from COPE for school-aged children, which was originally developed for adolescents (Melnyk et al., 2013). The original COPE program was implemented over seven sessions for 30 min each session.
For the adaptation, the first two authors integrated asthma information from the National Guidelines for the Diagnosis and Management of Asthma Expert Panel Report 3 (National Heart, 2007), and asthma concerns/situations cited by children in focus groups were incorporated into the sessions. Table 1 describes the intervention content areas.
COPE for Asthma is a manualized program. The interventionist was trained by the developer of the original program (Dr. Bernedette Melnyk), which consisted of an 8 hr in-person training related to the underpinnings and implementation of the manualized program. An intervention log was kept to document attendance, document group dynamics, and to ensure that the COPE for Asthma manual was followed and topic content was covered. Four fidelity observations were completed by a graduate research associate who used a fidelity checklist to assess intervention delivery as specified by the manual. Knowledge assessments (i.e., receipt of the intervention) were completed at the end of each group to assess participants’ comprehension of the content. The questions included true/false, multiple choice, matching, and fill in the blanks.
The consent and assent forms were verbally reviewed with each CG and child in a private area of the school or other CG-preferred location. CGs were consented and completed surveys but did not receive the intervention. To confirm that the participants understood the consent and assent process, the first author asked each person to repeat back in their own words to assure understanding that (a) this is a research project, (b) the purpose of the study, (c) potential risks and benefits of participation, (d) the incentives were for participation, not completion, (d) they could stop participation at any time without negative repercussions, and (e) how to contact the interventionist (first author) and the IRB for questions or concerns. Assent for each child was reestablished at each session by asking them individually (not in front of the group) whether they wanted to participate.
Children scoring ≥30 on the SCARED measure or incurred a t score ≥70 on the PROMIS depression measure were referred to school staff (i.e., school nurse, social worker, psychologist, or guidance counselor) for follow-up per the district’s protocol. The study team then sent a form referral letter to the consenting CG. Additionally, children were referred if they expressed current thoughts, history of self-harm or harm to others. The protocol specified making referrals to the county children’s services for any child reporting concerns of abuse, neglect, or dependency.
Thirty-three children and their CGs were consented and assented. One child and CG moved prior to intervention delivery, resulting in 32 children completing the program and included in the intervention effects analyses. Figure 1 displays the consolidated standards of reporting trials (CONSORT) flow diagram. The child participants were between 8 and 12 years of age with a mean age of 9.42 years (SD = 1.42 years). Table 2 details the child characteristics.
The majority of CGs were mothers (n = 26, 78.8%). Three fathers, two grandmothers, one aunt, and one guardian comprised the other CGs. Their ages ranged from 27 to 57 years with a mean age of 36.91 years (SD = 8.58). Most CGs reported they were single (n = 17, 51.5%), followed by a significant other living in the home (n = 12, 36.4%). Twenty-one CGs (63.6%) reported they receive public assistance.
Details of the feasibility and acceptability were reported in a previous manuscript (McGovern et al., 2019). In short, COPE for Asthma was found to be highly feasible and acceptable except for the practice worksheet completion.
Preliminary Effects of the Intervention at 6-Weeks Postintervention
Table 3 shows the mean scores at each time point and the range of reliability estimates for each measure by time period. Even with the small sample size, a number of the measures demonstrated acceptable reliability. Table 4 details the RM-ANOVA findings, which indicated a significant reduction in anxiety reported by the child participants. values can be changed as F()], N = 32; F (1.44, 44.74) = 4.66; p value = .02; =.13, and behavioral symptoms reported by the CGs, F (2, 62) = 2.80; p value = .03; = .11. Additionally, significant increases were observed for personal beliefs and confidence in managing stress, F (1.75, 54.17) = 2.86; p value = .07; = .08, asthma management self-efficacy, F (2, 62) = 7.06; p value = .002; = .19, asthma illness representations, F (1.75, 54.24) = 6.92; p value = .003; = .18, and asthma control, F (2, 62) = 4.21; p value = .02; = .12. All outcomes were trending toward improvement. Table 5 illustrates the results for the RM-ANOVA among a subgroup of participants scoring ≥30 on anxiety at baseline. Interestingly, delayed effects were found in the reduction of anxiety and improvement in asthma control for the whole group of participants. Significant reductions in anxiety (overall) from baseline (T0) to immediately postintervention (T1) were not observed. However, significant findings were evident from baseline to 6-weeks posttest (T2) for each measure.
No children scored high on the depression measure (PROMIS-P SF) at baseline. Among this group, a significant reduction in anxiety was found with a large positive effect size F (1.23, 12.28) = 5.14; p value = .03; = .34. Increases in personal beliefs and confidence in managing stress F (2, 20) = 3.21; p value = .06; = .24, asthma management self-efficacy F (2, 20) = 3.30; p value = .06; = .25, and asthma illness representations F (2, 20) = 15.15; p value = .000; = .60 were noted and had large positive effect sizes. All participants in this group (and any child participant scoring ≥30 on the SCARED measure at subsequent data collection points) were referred to the school guidance counselor or school nurse for follow-up. As far as the interventionist is aware, only one of these participants went to a therapist and was placed on a waiting list.
Of the 19 (59%) children prescribed an asthma controller medication, significantly fewer missed doses were reported over the course of the study (Mauchly’s test nonsignificant; N = 19; F (2, 36) = 3.89; p value = .03; = .18). No significant difference was found among those who were or were not on a controller medication before or after the study.
Short-Acting Medication Use, Emergent Care Use, and School Absences
Over the three time points, there were no significant changes in the short-acting medication use (Mauchly’s test was significant, so Greenhouse–Geisser was used; F (1.56, 48.43) = .62; p value = .50; = .02). Likewise, there was no significant change in asthma-related emergency department/urgent care use (Mauchly’s nonsignificant; F (2, 62) = 1.00; p value = .37; = .03). School absences were measured by data from the school records (i.e., absences due to any cause). No significant changes related to school absences were identified. However, it should be noted that several children missed weeks of school due to traveling for an out-of-town funeral and having a sibling or CG that was hospitalized, which prevented the children from getting to school.
Several questions were included at the final data collection time point for the child participants related to cognitive behavior skill use, frequency, whether they would have wanted their CG to learn what they learned in the groups, and whether they would have preferred to learn with their CG as opposed to a lunch-bunch group. Twenty-nine (88%) of the children reported practicing the skills at least once since the lunch-bunch groups met. Seven children (22%) reported using the skills several times a day; five (16%) reported using a skill once a day; four each (13% and 13%) reported using the skills every week or several times per week. Nine children (28%) reported using the skills once or twice since the lunch-bunch groups met. Table 6 displays the specific skills reportedly used by the participants.
Most of the children (n = 23, 72%) reported they would like their CGs to learn the skills they did during the group. Only three (9%) stated they would have preferred to complete COPE for Asthma with their CG instead of in the lunch-bunch groups. Ten (31%) children wanted to keep the format as the hard copy of the manual, while 10 children (31%) would like to have only the practice sheets online, but the manual in paper form. Twelve (38%) children would rather have both the manual and practice sheets online/electronic form. Children who would rather have COPE for Asthma online were more likely to be older F (1, 30) = 2.96; p value = .096. All CGs reported that their child(ren) have access to a smart phone or computer every day.
CG interest in participating was split: 15 (47%) indicated that they would not like to learn what their child(ren) learned in COPE for Asthma, while 17 (53%) reported they would like to learn the information in the program. Two thirds of the CGs (n = 22, 69%) would have appreciated receiving the weekly information sheets online, and 21 (66%) would have preferred the surveys online.
Intervention delivery. Group sizes ranged from four to five participants per group. Groups commenced once all participants were present, barring student school absences. The average amount of time for weekly session content was 28.7 min, with a range of 25–30.4 min. While the same room was designated for the sessions at each school, a room change was needed at one school once due to an administrator’s conference with a parent.
Fidelity of the intervention. The fidelity checklist average was 95%. The average for the session review comprehension questions was 94.7% with weekly averages ranging from 88% to 100%. Any questions answered incorrectly were promptly reviewed with the participants. One multipart question was discarded due to difficulty (most groups needed help with it). Otherwise, participants demonstrated acceptable understanding of the content in the sessions.
The results of this study are promising for children with asthma and comorbid symptoms of anxiety. The population of interest, 8- to 12-year-old children with asthma and comorbid symptoms of anxiety at baseline, reported fewer symptoms of anxiety with medium to large effect sizes, while personal beliefs and confidence in managing stress, asthma management self-efficacy, and asthma illness representations all increased, also with medium to large effect sizes postintervention.
Teaching children about their asthma along with coping skills for symptoms of anxiety may help prepare these youth for current challenges and for those that lie ahead during the teenage years. Many of the participants reported that they practiced the coping skills after the program ended; this was an encouraging finding. The hope is that the participants will continue to experience reduced anxiety and improved confidence by doing so, which may strengthen the likelihood of their use in the future.
Adolescence is a period of rapid growth and change which can be particularly tumultuous for youth with chronic conditions. Another finding from the current study was the CG report of fewer missed doses of asthma controller medication postintervention, which could translate to better asthma control over time. Coupled with the child report of understanding the seriousness of asthma symptoms/not to ignore asthma symptoms, we hope that the participants will have the confidence to manage their asthma and feelings of anxiety in the face of wanting to blend in as a teenager (Badawy et al., 2017; McGovern et al., 2019), particularly since the risk of death due to asthma increases during the adolescent and young adult years (Centers for Disease Control and Prevention, 2019).
CGs reported fewer pediatric symptoms of emotional and behavioral problems in their children postintervention. The effects for all results were more pronounced for children who reported particularly high symptoms of anxiety at baseline. Most of the children reported using the cognitive behavioral skills weeks after the intervention, which is most encouraging for developing positive habits and sustained improvements in physical and mental health.
COPE for Asthma is a brief, asthma education and cognitive behavioral skills-building intervention that can be implemented during the school day. While most school nurses may have too many competing priorities to implement the program as lunch-bunch groups, it may be possible at a different time during the day. Flexibility is key when considering implementation of such a program. Whether school nurses can implement programs during the school day may depend on the dynamics of the school, administrative support, and percentage of time that a nurse is in the particular school building. School counselors also implement small group interventions during the school day and may be receptive to partnering with school nurses with the implementation of COPE for Asthma. Another possibility is for trained and precepted nursing students to act as the interventionist. Nursing students completing their community placement with licensed school nurses could be an excellent opportunity for the student and, at the same time, provide a benefit for the children and the school nurse. Seeking viable options to scale up implementation is a future step for helping children with asthma and anxiety/depressive symptoms on a larger scale.
School nurses are often aware of students who may be considered “frequent flyers,” or children who visit the school nurse numerous times during the school day. Many reasons can contribute to a student making repeated trips to the nurse. The first author (CMM) was a school nurse in a large urban district in the Midwest for 12 years and had experience with this population. Anecdotally, a system was put into place for these students that worked. If all medical and academic concerns had been addressed/ruled out and the frequency of visits continued, she would schedule specific times for these students to “check-in” with her with the understanding that they would stay in class between the check-in times. Specifically, she would advise the student(s) to stop by the nurse’s office twice each day: after breakfast and after lunch. Students would enthusiastically agree to the plan and for a few days, would stop in and let the school nurse know how they were doing that day/how their day was going. The students stayed in class and the system was less disruptive for the school nurse. Invariably, after the routine was followed for a few days, the student visits would become less frequent or stop. Reasons for a child/student’s frequent visits may be due to the need for connection, anxiety, or some other reason; however, intentionally addressing the behavior appeared to help the student and allowed the nurse to attend to other duties with, perhaps, fewer interruptions.
Children with asthma and symptoms of anxiety may have a similar experience with a program such as COPE for Asthma. Time formally spent on attending to symptoms of anxiety and asthma education for this population may save time and reduce unnecessary trips to the school nurse and/or acute care setting. Measuring change in missed instructional time as well as academic performance for the child participants of COPE for Asthma was beyond the scope of the current study, though will be assessed in future studies.
COPE for Asthma was a novel adaptation of a well-established, evidence-based, theory driven intervention. Additionally, this was the first time that the child version of COPE was implemented with small groups in the school setting. The results from the qualitative feedback (McGovern et al., 2019) will be integrated into the program.
Our study has several limitations that should be considered while interpreting the results. We used a one-group design and had a small sample size. While appropriate for piloting a newly adapted intervention, the ability to establish causality is limited.
Subsequent studies should include an objective measure to evaluate lung function, such as a pulmonary function test. Obtaining data to monitor changes in lung function will benefit future iterations of the program. Future research should also implement a randomized controlled design with an attention control intervention. Doing so will strengthen the rigor of the study outcomes.
Guided by an integrated conceptual framework of CT and the CSM of self-regulation, the goals of COPE for Asthma included reducing anxiety, increasing beliefs about one’s ability to effectively manage stress and the ability to manage asthma, as well as improvement in symptom interpretation and more accurate illness beliefs. Results from this study support the integrated framework and indicate a step in the right direction related to these factors. Reducing anxiety and improving symptom interpretation, which subsequently inform illness representations, may result in improved long-term asthma control. Continued skill-use by the participants is very encouraging. CGs indicated fewer missed doses of their child(ren’s)’s controller medication which should improve asthma control over time. These are substantial gains that deserve further exploration and dissemination.
The content is based solely on the perspectives of the author and does not necessarily represent the official views of the National Institutes of Health or other sponsors. This study is registered at www.clinicaltrials.gov NCT03481673.
Manuscript preparation by C. M. McGovern was supported by a Ruth L. Kirschstein National Research Service Award (Predoctoral—T32NR014225; Postdoctoral—T32NR007091-23), American Nurses Foundation, Sigma Theta Tau International/Midwest Nursing Research Society, National Association of Pediatric Nurse Practitioners, and Sigma Theta Tau Epsilon. The first author would also like to acknowledge Dr. Dawn Anderson-Butcher and Dr. Barbarra Warren for their guidance with the study.
All authors contributed to the conception of the manuscript, contributed to the acquisition and analysis of the data, were involved in the critical revisions, gave the final approval and agreed to be accountable for all aspects of work ensuring integrity and accuracy. The manuscript was drafted by C. McGovern.
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Bernadette Melnyk has a company, COPE2THRIVE that disseminates the COPE program.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The first author (CMM) received funding support for the research from a Ruth L. Kirchstein National Research Service Award (Predoctoral - T32NR014225; Postdoctoral - T32NR007091-23), the American Nurses Foundation, Sigma Theta Tau International/Midwest Nursing Research Society, National Association of Pediatric Nurse Practitioners, and Sigma Theta Tau Epsilon Chapter.
Colleen McGovern, PhD, MPH, RN https://orcid.org/0000-0002-4616-5121
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Colleen McGovern, PhD, MPH, RN, is a postdoctoral fellow at the School of Nursing, University of North Carolina at Chapel Hill.
Kimberly Arcoleo, PhD, MPH, is a research professor at the University of Rhode Island.
Bernadette Melnyk, PhD, RN, is a dean and a professor at The Ohio State University and also a professor of Pediatrics & Psychiatry at The Ohio State University.
1 School of Nursing, University of North Carolina at Chapel Hill, NC, USA
2 University of Rhode Island, Providence, RI, USA
3 College of Nursing, The Ohio State University, Columbus, OH, USA
4 College of Medicine, The Ohio State University, Columbus, Ohio, USA
Corresponding Author:
Colleen McGovern, School of Nursing, University of North Carolina at Chapel Hill, 4008 Carrington Hall CB#7460, Chapel Hill, NC 27599, USA.Email: mcgovern@unc.edu
