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Page 1: Perceptions and Attitudes of Adolescents with Asthma

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

JOURNAL OF ASTHMA

Vol. 40, No. 2, pp. 207–211, 2003

ORIGINAL ARTICLE

Perceptions and Attitudes of Adolescents with Asthma

Robyn Cohen, M.D., Karen Franco, M.D., Ferrell Motlow, M.D.,

Marina Reznik, M.D., and Philip O. Ozuah, M.D., Ph.D.*

Albert Einstein College of Medicine, Children’s Hospital at Montefiore, Bronx,

New York, USA

ABSTRACT

Background. Psychosocial factors can limit one’s ability to effectively manage asthma.

This can result in asthma morbidity that limits quality of life. While self-perceptions of

asthmatic children and parents have been studied, less is known about self-perceptions

of inner-city adolescents with asthma. Objective. To examine perceptions and atti-

tudes to treatment among inner-city adolescents with asthma. Design/Methods. We

conducted a multistaged stratified sample survey at a high school located in the Bronx,

NY. First, an asthma-screening survey was administered to 3800 registered students.

Then, we identified a subset of 200 children with the most positive screening results for

asthma. Next, a 32-item self-completion questionnaire was administered to this cohort.

Students were surveyed regarding severity of asthma, perceptions and attitudes, and

demographic information. Differences in proportions were tested by Chi-square anal-

yses. Pearson rank-order correlation and multiple logistic regression were used to assess

the relationship between perceptions and attitudes to self-treatment. Results. A total

of 160 (80%) students participated. Mean age was 15.7 years. Of the respondents, 63%

were female. 68% were Hispanic, 26% were African American. 33% had weekly symp-

toms, and 14% had daily symptoms. Additionally, 41% did not know the name of their

asthma medicine. Only 38% reported bringing an ‘‘asthma pump’’ when leaving the

house. While 70% reported feeling in control over their asthma symptoms, 63%

reported feelings of anxiety and 39% could remember a time when they felt like they

were going to die from asthma. Subjects who reported feeling in control over their

asthma were more likely to take an asthma pump with them when leaving the house

(r¼ 72, p¼ 0.004). Only 39% had disclosed their asthma to their friends, and 29% felt

embarrassed about having an asthma attack in front of their friends. Subjects who felt

*Correspondence: Philip O. Ozuah, M.D., Ph.D., Vice Chairman for Clinical and Educational Affairs, Albert Einstein

College of Medicine, Children’s Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY 10467, USA; Fax: (718)

741-2498; E-mail: [email protected].

207

DOI: 10.1081/JAS-120017992 0277-0903 (Print); 1532-4303 (Online)

Copyright & 2003 by Marcel Dekker, Inc. www.dekker.com

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Page 2: Perceptions and Attitudes of Adolescents with Asthma

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

embarrassed about their asthma were significantly less likely to take their asthma pumps

with them (r¼ 0.98, p<0.001) and less likely to use their medications in front of their

friends (r¼ .87, p<0.001). Conclusions. Adolescents in this study reported feelings of

anxiety, fear, and embarrassment about their asthma. Feelings of control over asthma

symptoms were associated with positive attitudes toward self-treatment, while embar-

rassment was correlated with negative attitudes. These findings have implications for

counseling adolescents with asthma about self-management strategies.

Key Words: Adolescents; Asthma; Attitudes.

INTRODUCTION

Asthma, a leading cause of morbidity and mor-tality among U.S. children, is known to be mediatedby psychosocial factors (1–3). Furthermore, childrenwith asthma have been shown to be at increasedrisk for psychological difficulties, including anxietyand depression (4,5). Studies have demonstratedreciprocal relationships between psychosocial factors,effectiveness of asthma management strategies, andasthma morbidity among children (6,7).

Despite extensive research about the psycho-social characteristics of asthmatic children and theircaretakers (8,9), less is known about adolescents withasthma. From a developmental perspective,adolescence can be a tumultuous transitional periodbecause of the desire for autonomy, a sense of invin-cibility, denial of disease, and susceptibility to peerpressure. For these reasons, fostering effective self-management strategies with asthmatic adolescentscan be particularly challenging (10,11). In thisstudy, we sought to examine the perceptions ofinner-city asthmatic adolescents and their attitudestoward self-treatment of their disease.

METHODS

Setting

The study was conducted at a public high schoolin the Bronx, NY, where 57% of the students wereLatino, 35% were African American, and 3% werewhite. Eighty-three percent of students at this schoolwere from families with incomes at or below 130% ofthe federal poverty level.

Design

We employed a multistaged stratified sampledesign. First an asthma-screening questionnaire was

developed, piloted, and modified. This instrumentwas administered to 3800 registered students ingrades 9 through 12. We identified a subset of 200students by positive responses to three questions:‘‘Do you think you have asthma?’’ ‘‘Do your parentsthink you have asthma?’’ and ‘‘Does your doctorthink you have asthma?’’ Students who answeredyes to all of these questions were considered eligibleto participate in the study. Next, we administered a32-item questionnaire to this cohort during a30-minute session arranged by school officials.

Instrument

The 32-item self-completion teen asthma ques-tionnaire (Appendix A) was developed by the authorsto evaluate several domains. Asthma severity wasassessed by asking about frequency of symptomsand about activity limitation. We assessed percep-tions and attitudes by asking students to agree ordisagree, using a 5-point Likert scale, with 12 state-ments about anxiety, control, embarrassment, andoptimism about the future. Demographic data werealso obtained.

Analysis

Differences in proportions of dichotomousvariables were tested by Chi-square analyses.Pearson rank-order correlation and multiple logis-tic regression were used to assess the relation-ship between perceptions and attitudes towardself-treatment.

RESULTS

Of the 200 eligible subjects, 160 (80%) completedthe questionnaire. The mean age of participants was

208 Cohen et al.

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Page 3: Perceptions and Attitudes of Adolescents with Asthma

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

15.7 years; 63% were female, 68% were Latino, and24% were born outside the United States (Table 1).Seventy-two percent had asthma symptoms at leastonce per month, 33% had weekly symptoms, and14% had daily symptoms. Thirty-five percentreported that their daily activities were limited bytheir asthma.

Forty-two percent of subjects experienced anxi-ety in relation to their asthma and 39% remembereda time when they were afraid of dying from asthma.Seventy percent perceived a sense of control overtheir asthma symptoms; however, only 38% reportedtaking an ‘‘asthma pump’’ when leaving the house.Subjects who felt control over their asthma weremore likely to take their asthma medications withthem (r¼ 0.72, p¼ 0.004).

In examining the impact of embarrassment onattitudes toward asthma, we found that 29% of par-ticipants were embarrassed by their asthma and 32%were embarrassed about taking asthma medicinein front of their friends. Only 39% had disclosedtheir asthma to their friends. Subjects who hadnot disclosed their asthma to their friends weremore likely to feel embarrassed by their disease(r¼ 0.95, p<0.001). Moreover, those who felt embar-rassed about their asthma were less likely to carrytheir asthma medications with them at all times(r¼ 0.98, p<0.001) and were less likely to use theirmedications in front of their friends (r¼ 0.87,p<0.001).

DISCUSSION

In this study, a group of adolescents repor-ted anxiety, fear, and embarrassment about theirasthma. Several had experienced an asthmaexacerbation severe enough that they thought

they were going to die. Although most felt somecontrol over their asthma symptoms, few actuallycarried their rescue medications with them.Subjects who were embarrassed about their asthmawere less likely to have their medications avail-able when needed. Perceptions of a sense ofcontrol over asthma and an expression of a willing-ness to discuss asthma with friends were positivelycorrelated with appropriate self-management ofasthma.

We believe this is the first study in the UnitedStates to examine perceptions and attitudes to treat-ment among adolescents with asthma. However, theresults of this study are consistent with results fromstudies from other countries. Gibson et al (1995)showed that among eighth-grade subjects inAustralia, 38% felt that using asthma medicine infront of others was embarrassing (12). Sibbald(1989) found that 25% of asthmatic adult subjectsin England expressed strong feelings of stigmaand pessimism, and that these were correlated withself-management (13). In contrast to our findings,van Es et al. (1998) found that asthmatic adolescentsin the Netherlands had disclosed their asthma totheir friends and were not ashamed of theirasthma (11). Reasons for these differences areunclear.

We note some limitations with our study, includ-ing reliance on self-report instead of objectivemeasures of asthma severity and behavior. This isa limitation of all self-report studies. A secondlimitation is a potential ‘‘absentee bias’’ because 40of the eligible 200-student cohort were absent fromschool on the day the questionnaire was completed.There may be differences between participants andnonparticipants. However, we were able toenroll 80% of eligible subjects. The teen asthma ques-tionnaire used in this study needs to be evaluated inother settings. It is not known whether a study ofa group of middle class or upper class adole-scents with asthma would provide different resultsfrom those in our study. Our study populationwas composed of primarily inner-city, poor, andminority children.

The results of this study have several impli-cations. Our findings suggest that helping teensto develop a sense of control over their asthmaand helping to lessen embarrassment with regardto medication use may be essential adjuncts tothe care of asthma in this population. Additio-nally, peer support groups and peer educatorsmay be beneficial in the care of adolescents withasthma.

Table 1. Characteristics of study participants.

Demographics

Female 63%

Latino 68%

African American 28%

Immigrant 24%

Mean age 15.7 years

Frequency of asthma symptoms

Monthly 72%

Weekly 33%

Daily 14%

Perceptions and Attitudes of Adolescents with Asthma 209

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Page 4: Perceptions and Attitudes of Adolescents with Asthma

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

REFERENCES

1. Weil CM, Wade SL, Bauman LJ, Lynn H,Mitchell H, Lavigne J. The relationship betweenpsychosocial factors and asthma morbidity ininner-city children with asthma. Pediatrics 1999;104(6):1274–1280.

2. Wade S, Weil C, Holden G, Mitchell H, Evans RIII, Kruszon-Moran D, Bauman L, Crain E,Eggleston P, Kattan M, Kercsmar C, Leickly F,Malveaux F, Wedner HJ. Psychosocial character-istics of inner-city children with asthma: adescription of the NCICAS psychosocial proto-col. National Cooperative Inner-City AsthmaStudy. Pediatr Pulmonol 1997; 24(4):263–276.

3. Miller JE. The effects of race/ethnicity andincome on early childhood asthma prevalenceand health care use. Am J Public Health 2000;90(3):428–430.

4. Bosley CM, Corden ZM, Cochrane GM. Psycho-social factors and asthma. Respir Med 1996;90(8):453–457.

5. ten Thoren C, Petermann F. Reviewing asthmaand anxiety. Respir Med 2000; 94(5): 409–415.

6. Perrin JM, MacLean WE Jr, Gortmaker SL,Asher KN. Improving the psychological statusof children with asthma: a randomized con-trolled trial. J Dev Behav Pediatr 1992; 13(4):241–247.

7. Evans R III, Gergen PJ, Mitchell H, Kattan M,Kercsmar C, Crain E, Anderson J, Eggleston P,Malveaux FJ, Wedner HJ. A randomized clini-cal trial to reduce asthma morbidity amonginner-city children: results of the NationalCooperative Inner-City Asthma Study. J Pediatr1999; 135(3):332–338.

8. Miles A, Sawyer M, Kennedy D. A preliminarystudy of factors that influence children’s sense of

APPENDIX A

Teen asthma survey

Do you cough/wheeze/have chest tightness every day? Y N

Do you cough/wheeze/have chest tightness every week? Y N

Do you cough/wheeze/have chest

tightness at least once a month? Y N

Do you take asthma medicine every day/every night? Y N

Do you take asthma medicines at least every week? Y N

Do you take asthma medicines at least every month? Y N

Think about your asthma when you answer these questions. Please circle your answers

Strongly

agree

Strongly

disagree

When I cough or feel short of breath,

I know what to do to feel better.

1 2 3 4 5

Coughing or feeling short of breath

makes me nervous.

1 2 3 4 5

All of my friends know I have asthma. 1 2 3 4 5

I always take an asthma pump with me

when I leave the house.

1 2 3 4 5

I get embarrassed when I feel short of breath. 1 2 3 4 5

I get embarrassed when I take asthma

medicine in front of my friends.

1 2 3 4 5

Many of my friends have asthma. 1 2 3 4 5

There are things I cannot do because

I have asthma.

1 2 3 4 5

I can remember a time when my asthma was so Bad that

I was afraid I was going to die.

1 2 3 4 5

In the future my life will be better than it is now. 1 2 3 4 5

I will do great things in the future. 1 2 3 4 5

I will live a long, healthy life. 1 2 3 4 5

210 Cohen et al.

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©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

competence to manage their asthma. J Asthma1995; 32(6):437–444.

9. Grus CL, Lopez-Hernandez C, Delamater A,Appelgate B, Brito A, Wurm G, Wanner A.Parental self-efficacy and morbidity in pediatricasthma. J Asthma 2001; 38(1):99–106.

10. Randolph C, Fraser B. Stressors and concernsin teen asthma. Curr Probl Pediatr 1999;29(3):82–93.

11. van Es SM, le Coq EM, Brouwer AI, Mesters I,

Nagelkerke AF, Colland VT. Adherence-relatedbehavior in adolescents with asthma: resultsfrom focus group interviews. J Asthma 1998;35(8):637–646.

12. Gibson PG, Henry RL, Vimpani GV, Halliday J.Asthma knowledge, attitudes, and quality of lifein adolescents. Arch Dis Child 1995; 73(4):321–326.

13. Sibbald B. Patient self care in acute asthma.Thorax 1989; 44(2):97–101.

Perceptions and Attitudes of Adolescents with Asthma 211

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Page 6: Perceptions and Attitudes of Adolescents with Asthma

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

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