Multimodal patient education program with stress management for childhood and adolescent asthma
Introduction
Asthma is a chronic inflammatory lung disease, characterized by airway obstruction, inflammation, and hyperresponsiveness to a variety of stimuli [1]. It is the most common chronic disease in childhood and adolescence. In Europe, the prevalence of childhood and adolescent asthma varies between 6 and 10% [2], [3]. However, there is a growing body of evidence for increasing prevalence rates, hospitalizations, and mortality among children and adolescents during the last decade, particularly in Western industrial nations [1], [2], [3]. Although more research is needed to identify the causes, the significant role of an impaired life style is suggested, leading to non-adherence to medical regimens [4].
The etiology of asthma is multifaceted including hereditary, allergic, infectious, and psychologic factors [5]. Psychological factors, such as distress, seem to be of greater importance for the maintenance and exacerbation than for the onset of chronic diseases (e.g. [6]). In particular, chronically ill children and adolescents have to cope with disease-related stressors proven to have a significant impact on the course of chronic conditions [7]. Coping with illness-related stressors in chronic diseases comprises four dimensions [8]: firstly, children and adolescents with asthma have to adhere to restrictive treatment regimens. LeFevre and Moussier [9] concluded that the high rise in mortality of adolescents with asthma is due to non-adherent behavior. Secondly, they have to deal with social isolation [10]. Thirdly, in spite of disparate findings some evidence suggests that they are characterized by an impaired self-concept and self-esteem [11], [12]. Fourthly, they have to adjust to a variety of emotional responses. Although inconclusive, results suggest that asthmatic children and adolescents compared with healthy contemporaries tend to develop more emotional problems, especially internalizing behavior problems, such as anxiety disorders and depression [13], [14]. Studies focused on variables which intervene between psychological adjustment and disease put emphasis on severity of disease and duration of illness [15]. Situational factors could also be determined referring to family factors, such as family interaction [11], family quality of life [15], and family rituals [16].
Additionally, individual factors were identified, such as illness uncertainty and attributional style [17]. These results are consistent with findings on the important role of children’s and adolescents’ capability to cope effectively with the chronic disease in the psychological adjustment (cf. [4], [18]). Avoidant coping which was increased in asthmatic adolescents in comparison to diabetic contemporaries [9] has proven to be a significant risk factor for adolescent depression in non-clinical samples [19]. Some researchers emphasized the considerable increase in mortality of asthmatic adolescents presumably due to more pronounced depression which interferes with adherent behavior [5], [9].
Taking into consideration that both factors, psychosocial stress and severity of disease, are interacting (cf. [6]) the relevance of intervention programs for the prevention of disease exacerbation becomes obvious. Diverse patient education programs were developed for children and adolescents with asthma (for review see [20]) focusing on information about illness and treatment as well as skills training including self-perception of asthma symptoms, self-care techniques, and social competence (cf. [4]). In sum, information about the disease led to significant improvements in children’s asthma knowledge [21]. Moreover, effective changes were demonstrated with regard to the child-oriented rehabilitation in inpatient settings [22], [23]. Programs carried out during outpatient rehabilitation were also effective [24], [25]. By applying family-oriented interventions significant improvements in parental coping strategies [26], parents’ and children’s knowledge as well as morbidity were revealed [27]. Thereby, age-dependent treatment effects were shown, suggesting to clarify age differences in intervention effects [27]. Further studies pointed to the superiority of an intensive inpatient family management program in comparison to an outpatient day camp [28]. Thereby, some results indicated that the effects weakened over the time course [22], [27], supporting the importance of booster sessions after rehabilitation.
However, implementation of stress management into education programs has been widely neglected. Thus, previous programs primarily included relaxation training and disease-related self-management techniques. Instead, improving individuals’ capacities of coping with common stressors was ignored, and this important resource of dealing adaptively with those most frequently occurring and demanding stressors was not considered. Furthermore, recent studies have ignored to evaluate intervention effects on subjective measures of coping with stress. This could give a further hint to children’s and adolescents’ quality of life which is the central outcome measure in research on patient education [29].
The aim of the present study was to investigate the efficacy of a multimodal education program for children and adolescents with asthma which was modified from Lob-Corzilius and Petermann [30] and adjusted to an inpatient setting. Into a shortened version of this patient education program a cognitive–behavioral stress management training was implemented. Short- and long-lasting effects on subjective health status and coping with common stressors were evaluated in comparison to this shortened version of the standard patient education program from Lob-Corzilius and Petermann [30]. It was hypothesized that the experimental group (EG) would show short- and long-lasting improvements in coping compared with the control group (CG). Moreover, it was expected that, 6 months after rehabilitation, the EG would gain significantly in subjective health status. A further goal of the present study was to examine age differences in the intervention effects. Given the scarce results in the literature, specific differences in rehabilitation outcome between age groups were not predicted.
Section snippets
Patients
Patients were recruited from the inpatient clinic for children and adolescents with chronic diseases, Fachklinik Sylt, Sylt/Westerland, Germany. Prior to rehabilitation, informed consent was obtained from each parent for their children’s participation in the study. At the beginning of rehabilitation, the two treatment groups did not differ with regard to severity of asthma (48.5% had mild, 8.8% moderate, 27.9% severe, and 8.8% very severe asthma according to WHO standards; 5.9% were missing).
Short-term intervention effects
Effects on self-reported satisfaction with health status were not demonstrated. Univariate analyses of variance on coping measures revealed no statistically significant main effects for treatment condition, age group, and time, respectively. Furthermore, interaction of treatment condition by age group did not reach statistical significance. But maladaptive coping style applied on academic stressors showed a tendency for the interaction of treatment condition and time (F(1,62)=3.33, P=0.073).
Discussion
The present study was aimed to explore the efficacy of a multimodal patient education program for children and adolescents with asthma. This program was applied during inpatient rehabilitation and contained a cognitive–behavioral stress management training as a major component. Effects were examined in comparison to a shortened version of the standard patient education from Lob-Corzilius and Petermann [30] which focused on information about disease-related knowledge and self-care techniques.
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