The Journal of School Nursing2025, Vol. 41(3) 383–389© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221085675journals.sagepub.com/home/jsn
AbstractAnxiety and depressive symptoms are associated with asthma-related acute care utilization. Few studies include rural adolescents. Asthma control may be the mechanism by which mental health affects acute care. This study explored associations between generalized anxiety, asthma-related anxiety, depressive symptoms, and acute care visits, and tested if asthma control mediates these associations among 197 rural adolescents with asthma. Data analysis included descriptive statistics and regression. Controlling for age, sex and race/ethnicity, asthma-related anxiety was associated with higher odds of acute care visits (OR = 2.09, 95% CI [1.42, 3.07]). Asthma control mediated this relationship: one unit increase in anxiety, on average, increased the odds of having any acute care visit by 5%. Generalized anxiety and depressive symptoms were not associated with acute care visits. Helping adolescents reduce their concerns regarding asthma while improving their self-management skill may potentially to reduce acute care among rural adolescents.
Keywordsadolescents, asthma control, asthma self-management, disease-specific anxiety, emergency department, mental health, rural, urgent care, school nurses
Asthma is the most common pediatric chronic illness in the United States with one in 12 children ages 0–17 years having asthma in 2016 (Zahran et al., 2018). Adolescents are a vulnerable group with increased risk of asthma and asthma-related morbidities (Bruzzese et al., 2019; CDC, 2021; Schneider, 2020; Zahran et al., 2018). Asthma is associated with poor academic outcomes across a range of indicators, including attendance, graduation rates and grades (Johnson et al., 2019; Koinis-Mitchell et al., 2019; Schneider, 2020; Sullivan et al., 2018).
Anxiety and depressive symptoms commonly co-occur with asthma (Dudeney et al., 2017; Opolski & Wilson, 2005) and are associated with poor asthma control and increased asthma-related acute care utilization (Bardach et al., 2019; Kulikova et al., 2021; Shams et al., 2018; Shankar et al., 2019). Asthma-related anxiety, or the fear regarding the illness, has recently been shown to be associated with better strategies for asthma self-management among children and adolescents (Bruzzese et al., 2011; Feldman et al., 2019). It is noteworthy that these studies regarding pediatric asthma and mental health have been conducted in predominately urban populations, with little attention being paid to rural youth. This represents an important gap in the literature given relatively high asthma prevalence and morbidity among rural adolescents (Estrada & Ownby, 2017; Fedele et al., 2016; Ownby et al., 2015).
Understanding mechanisms that explain the association between mental health and acute care visits for asthma is a first step in understanding how mental health comorbidities impact health care utilization. Some postulate that asthma control is the mechanism by which mental health affects acute care (Bardach et al., 2019; Kulikova et al., 2021; Shankar et al., 2019). Mental health symptoms may worsen asthma control, which in turn can increase asthma-related acute care utilization. More specifically, mental health symptoms may impede self-management (Leonard et al., In press), and reduced self-management is known to worsen asthma control (GINA, 2020), increasing acute care visits. To the best of our knowledge, this is the first study to test this mediational pathway in adolescents.
Thus, this study aimed to investigate associations between mental health (i.e., generalized anxiety, asthmarelated anxiety, and depressive symptoms), recent acute care visits for asthma, and asthma control. We hypothesized that asthma control would mediate the significant relationship between mental health and asthma-related acute care visits.
This study is a secondary analysis of baseline data from a clinical trial testing the effectiveness of a school-based asthma intervention to improve asthma outcomes among rural adolescents. Participants were drawn from eight high schools in rural communities of South Carolina. The Institutional Review Boards of Columbia University and the Medical University of South Carolina approved all study procedures, which took place at the school.
To recruit students for the trial, all students in a school were asked to complete a brief screening survey to identify who met enrollment criteria for the clinical trial, which was reporting being diagnosed with asthma by a health care provider and having at least one sign of poorly controlled asthma (e.g., symptoms three times a week, at least one Emergency Department visit or hospitalization for asthma in the past 12 months). Trained study staff then explained the clinical trial to eligible students and distributed consent and assent packages to students to bring home; study personnel collected signed caregiver consent and student assent forms from students on subsequent visits to the school. During Winter 2019 and 2020, trained staff completed baseline assessments with 200 participants, who were each compensated $15. We excluded three participants from this study due to missing data on sex and/or mental health outcomes, resulting in a final sample size of 197.
Socio-demographic and Asthma Characteristics. On the screening survey, adolescents reported their date of birth (which was used to compute age), sex, and race/ethnicity. At baseline, they reported additional socio-demographic characteristics (i.e., if they have insurance and if they have a place to receive health care), and asthma clinical characteristics (e.g., number of days with symptoms and nights woken the past 2 weeks, and if currently taking asthma medication).
Mental Health. Adolescents completed the nine-item generalized anxiety subscale of the Screen for Child Anxiety and Emotional Disorders (SCARED; (Birmaher et al., 1999; Birmaher et al., 1997) where they indicated the extent to which they feel worried and nervous. Responses were evaluated on a 3-point Likert scale (0 = not true or hardly ever true, 2 = very true or often true). Individual responses were summed for a total score (range 0–18); higher scores indicate more generalized anxiety.
To measure asthma-related anxiety, adolescents completed the Youth Asthma-related Anxiety Scale (Bruzzese et al., 2011); they indicated on 9 items the extent to which they felt nervous or worried about their asthma in the last two weeks (0 = never, 5 = always). Responses were averaged for each participant with higher scores suggesting more asthma-related anxiety.
The Center for Epidemiologic Studies Depression Scale (CES-D; (Radloff, 1991) was used to assess depressive symptoms. This validated scale consists of 20 items (e.g., I was bothered by things that usually don’t bother me) with responses on a 4-pt Likert scale (0 = rarely or none of the time (less than 1 day), 3 = most or all of the time (5–7 Days)). Individual responses were summed for a total score (0–60); higher scores indicate worse depressive symptoms.
Asthma Control. To measure this construct, the five-item Asthma Control Test (ACT; (Schatz et al., 2009; Schatz et al., 2007) was used. Adolescents indicated the frequency in the past four weeks that they had symptoms, activity limitations, and used a rescue inhaler, and rated their asthma control. Scores range from 5 to 25, with lower scores indicating worse control.
Acute Care Visits for Asthma. Adolescents completed two questions regarding the number of times in the last 3 months they went (1) to a healthcare provider’s office or clinic for immediate or urgent treatment for asthma, and (2) to the emergency room for asthma symptoms. Responses were recoded into yes/no for each type of visit and then collapsed for had any acute care visits for asthma (yes/no).
Prior to statistical modeling, data were thoroughly checked for any potential data entry errors and missing data. Descriptive statistics of participants’ characteristics (mean and standard deviation for continuous variables and frequency for categorical variables) were generated. All analyses were conducted using R (version 4.1.0).
Generalized linear mixed effect models were used to assess whether symptoms of generalized anxiety, asthma-related anxiety and depressive symptoms are associated with any acute health care visits in the past three months, respectively, as well as if mental health was associated with asthma control. School was included as a random intercept to account for potential correlation in outcome measures within each school. In all analyses, due to known demographic differences in asthma (CDC, 2019), we controlled for potential confounding effects due to age, sex, and race/ethnicity. Note that there were 15 participants with missing race/ethnicity information, we included these participants in the analyses with race/ethnicity variable coded as missing. Bonferroni correction was used to control for the familywise error rate at 0.05 level.
To determine whether asthma control was a potential mediator, subsequent mediation analyses would be performed if a significant relationship between any of the mental health outcomes (i.e., asthma-related anxiety) and the past three-month acute health care visits existed. Specifically, the causal mediation effect represents the indirect effect of asthma-related anxiety on the past three-month acute health care visits through asthma control. Mediation analysis approach (Imai et al., 2010) implemented in R package mediation (Tingley et al., 2014) was used to assess average mediation effect and its confidence interval.
Table 1 summarizes participant characteristics. Adolescents were on average, 16.32 (SD = 1.19) years old and mostly female (71.1%). The majority self-identified as Black (68.85%), followed by White (21.31%), with the remaining adolescents (9.84%) identifying as another race/ethnicity. Most adolescents had health insurance (86.80%). Almost 70% reported taking either a controller or quick reliever medication for their asthma. About thirty percent had at least one acute care visit for their asthma in the last three months. ACT scores averaged 18.39 ± 3.75. Mean scores for generalized anxiety, asthma-related anxiety, and depressive symptoms were 8.89 (SD = 4.30), 1.63 (SD = 0.92), and 19.81 (SD = 10.28), respectively.
Controlling for age, sex and race/ethnicity, more asthma-related anxiety was associated with higher odds of any acute care visit for asthma (OR = 2.09, 95% CI [1.42, 3.07]). Better asthma control was also associated with lower odds of any urgent health care visit in the last 3 months (OR = 0.80, 95% CI [0.73, 0.88]) and more asthma-related anxiety was associated with worse asthma control (β = −2.13, p < 0.001). Generalized anxiety (p = 0.36) and depressive symptoms (p = 0.10) were not associated with any urgent health care visit in the last 3 months.
Given the significant association between asthma-related anxiety and any asthma-related acute care visit, and between asthma control and any asthma-related acute care visit, we tested the potential mediating role of asthma control (see Figure 1). Mediation analysis decomposed the effect of asthma-related anxiety on any urgent health care visit into indirect and direct effects with indirect effect explaining the effect working through asthma control and direct effect explaining the effect working through other mechanism. Figure 1 showed that increased asthma-related anxiety was associated with decreased asthma control (β1 = −2.13, p < 0.001), which in turn increased the odds of having acute care visit (β2 = −0.03, p = 0.003). The odds ratio of the specific indirect effect of asthma-related anxiety through asthma control is 1.05 (indirect effect = 0.046, p < 0.001), indicating that on average, one unit increase in asthma-related anxiety increased the odds of having any acute care visit by 5% through its effect on asthma control. Mediation analysis results suggested that 49.62% of total effect between asthma-related anxiety and any urgent visits was mediated by asthma control.
To our knowledge, this is the first study investigating the association between symptoms of mental health comorbidities (i.e., generalized anxiety, asthma-related anxiety, and depressive symptoms) and asthma-related acute health care utilization among rural adolescents with at least one sign of poorly controlled asthma. We found that asthma control partially mediated the significant relationship between asthma-related anxiety and acute care utilization. One possible explanation for our findings is that it may be too cognitively taxing for adolescents to cope with asthma-related anxiety and to care for their asthma symptoms simultaneously (Bardach etal.,2019). Asaresult, their ability to successfully manage both sets of symptoms is reduced resulting in worse asthma control and thus more acute care visits (Bardach et al., 2019). Alternatively, asthma-related anxiety may reduce adolescents’ self-efficacy to care for their asthma, which in turn undermines their ability to manage their illness and thus asthma control (Turi et al., 2021). It is also plausible that asthma-related anxiety may decrease asthma control by increasing proinflammatory cytokines (Cooley et al., 2022). Given the limited research on asthma-related anxiety, these hypotheses warrant further investigation.
Neither generalized anxiety symptoms nor depressive symptoms were associated with asthma-related acute care utilization. These findings differ from previous research on urban youth that found higher rates of generalized anxiety symptoms and depressive symptoms were related to more asthma-related acute care (Bardach et al., 2019; Shams et al., 2018; Shankar et al., 2019). These divergent findings are possibly due to methodological differences. For example, considering a diagnosis or clinical cut-off of anxiety or depression may have revealed a different relationship than considering symptomatology. Similarly, a longer time frame to capture asthma-related acute care visits than the 3-month window used in this study, as well the inclusion of hospitalizations in the definition of acute care visits may have resulted in a greater likelihood of experiencing such acute care visits. Additionally, this study dichotomized acute care visits while other investigators consider the total number of visits. Alternatively, the current study is unique in its query regarding asthma-related anxiety, which was asked prior to generalized anxiety and depressive symptoms in the assessment battery. This measurement approach may have lessened the adolescent’s focus on generalized anxiety or depressive symptoms and allowed for a more specific relationship between asthma-related anxiety and acute care visits to emerge; when adolescents with asthma are provided an opportunity to report specifically on anxiety related to asthma, they may change their response style to general anxiety and depression measures. It is also possible that the relationship between mental health and asthma-related acute care utilization in rural adolescents differs compared to that of urban adolescents, and this needs to be explored in future research.
This study had several limitations. It relied exclusively on self-reported questionnaires which are subject to potential response bias. Future studies may want to include objective measures of asthma utilization and use multiple informants who report on the adolescents’ mental health symptoms. Also, this study was a secondary data analysis precluding our inclusion of additional variables that may be related to health care utilization, mental health, or asthma control (e.g., use of inhaled substances, family functioning). Additionally, our sample was comprised of predominately black and white adolescents; thus, our findings may not generalize to other racial/ethnic groups.
Rural youth with asthma face unique challenges to asthma and mental health care, including access to health care providers both for primary care and specialty care, lack of transportation to health care providers, and low trust of healthcare providers (Blackstock et al., 2018; Estrada & Ownby, 2017; Hardin et al., 2021; Hardin et al., 2018). Additionally, stigma is a particular concern, especially for mental health, because of the potential lack of anonymity in smaller, close-knit communities (Blackstock et al., 2018). School nurses are uniquely positioned to work with adolescents to overcome these barriers to care. Our findings suggest that as part of their routine asthma care, school nurses screen asthma patients for asthma-related anxiety, and address both poorly controlled asthma and the anxiety. Such screenings are feasible if a validated, brief screening tool, such as the scale used in this study (Bruzzese et al., 2011), are integrated into practice. If resources are limited, school nurses could focus their attention on those who worry about their asthma or who have asthma-related school absences and/or poor school performance as both are associated with poorly controlled asthma. School nurses helping adolescents improve their asthma self-management skills and confidence to implement these skills, as well as help them reduce their fears and concerns regarding asthma. This could be accomplished through education, behavioral interventions, and counseling to strengthen asthma control. Because rural students often have lengthy commutes on school buses (Lavalley, 2018) and lack access to public transportation, rural students may not be able to attend special programs before or after school (Umstattd Meyer et al., 2016). Thus, it is recommended to have these services offered during the school day. To sustain such interventions, school administrators may want to consider partnering with local medical centers to bring a school-based health center (SBHC) to the school or a mobile health van, should the school be too small to sustain a SBHC.
School nurses are also in the ideal position to intervene with caregivers and work with primary care providers. For example, school nurses could provide telehealth options with caregivers to help instruct them on how to help their adolescent manage his or her asthma. They can also foster communication with caregivers and primary care providers where they each share information regarding the adolescents’ asthma control, fears regarding the asthma and self-efficacy to care for their asthma; this multiprong communication network may help to strengthen the adolescent’s asthma control. School administrators may want to secure resources to allow for the telehealth option with caregivers to teach caregivers how to help their adolescent manage his or her asthma. If internet options limit telehealth, administrators may want to engage the services of community health workers or asthma educators.
In summary, the study suggests that asthma-related anxiety may be associated with worsened asthma control and increased urgent care hospitalizations. The significant relationship between asthma-related anxiety and acute care visits was partially mediated by asthma control. We hypothesized that anxiety and depressive symptoms would also lead to increased asthma-related hospitalization; however, asthma-related anxiety was the only significant relationship between psychological comorbidities and increased urgent care visits. Our results suggest rural adolescents are more likely to seek urgent care hospitalization when they have both poorer asthma control and more asthma-related anxiety. Addressing asthma and mental health concurrently has the potential to lead to the most successful treatment outcomes, reducing asthma-related acute care among rural adolescents. Future studies should continue to develop the relationship between mental health and urgent care utilization to better understand the mechanism that drives the relationship.
All authors contributed to the conception of the article, acquisition as well as analysis of the data, drafting of the article along with the critical revisions. All agree to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Heart, Lung, and Blood Institute (R01 HL136753, PI: Bruzzese); the content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official-views of the National Institutes of Health.
Jean-Marie Bruzzese https://orcid.org/0000-0002-1866-488X
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Maya R. Castiblanco is a student at Bates College, Lewiston, ME, USA; for part of this study she was a research assistant at the Medical University of South Carolina, Charleston, SC, USA.
Sharon Kingston, PhD is an Associate Professor of Psychology at Dickinson College, Carlisle, PA, USA.
Yihong Zhao, PhD is a Professor of Data Science at the Columbia University School of Nursing, New York, NY, USA.
Amarilis Céspedes, PhD is a Project Director Science at the Columbia University School of Nursing, New York, NY, USA.
Jennifer Smith Powell, BS is a Program Coordinator at the Medical University of South Carolina, Charleston, SC, USA.
Jean-Marie Bruzzese, PhD is a Professor of Applied Developmental Psychology at the Columbia University School of Nursing, New York, NY, USA.
1 Bates College, Lewiston, ME, USA
2 Dickinson College, Carlisle, PA, USA
3 Columbia University School of Nursing, New York, NY, USA
4 Medical University of South Carolina, Charleston, SC, USA
Corresponding Author:Jean-Marie Bruzzese, PhD, Professor of Applied Developmental Psychology (in Nursing), Columbia University School of Nursing, 560 West 168th Street, New York, NY 10032, USA.Email: jb3958@cumc.columbia.edu
