Cognitive behavioural therapy (CBT) for adults and adolescents with asthma.

BACKGROUND: People with asthma have a higher prevalence of anxiety and depression than the general population. This is associated with poorer asthma control, medication adherence, and health outcomes. Cognitive behavioural therapy (CBT) may be a way to improve the quality of life of people with asthma by addressing associated psychological issues, which may lead to a lower risk of exacerbations and better asthma control. OBJECTIVES: To assess the efficacy of CBT for asthma compared with usual care. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also searched reference lists of all primary studies and review articles and contacted authors for unpublished data. The most recent searches were conducted in August 2016. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) comparing any cognitive behavioural intervention to usual care or no intervention. We included studies of adults or adolescents with asthma, with or without comorbid anxiety or depression. We included studies reported as full text, those published as abstract only, and unpublished data. DATA COLLECTION AND ANALYSIS: Two or more review authors independently screened the search results, extracted data, and assessed included studies for risk of bias. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MDs) or standardised mean differences (SMD) where scales varied across studies, all using a random-effects model. The primary outcomes were asthma-related quality of life and exacerbations requiring at least a course of oral steroids. We rated all outcomes using GRADE and presented our confidence in the results in a 'Summary of findings' table. MAIN RESULTS: We included nine RCTs involving 407 adults with asthma in this review; no studies included adolescents under 18. Study size ranged from 10 to 94 (median 40), and mean age ranged from 39 to 53. Study populations generally had persistent asthma, but severity and diagnostic measures varied. Three studies recruited participants with psychological symptomatology, although with different criteria. Interventions ranged from 4 to 15 sessions, and primary measurements were taken at a mean of 3 months (range 1.2 to 12 months).Participants given CBT had improved scores on the Asthma Quality of Life Questionnaire (AQLQ) (MD 0.55, 95% confidence interval (CI) 0.17 to 0.93; participants = 214; studies = 6; I(2) = 53%) and on measures of asthma control (SMD -0.98, 95% CI -1.76 to -0.20; participants = 95; studies = 3; I(2) = 68%) compared to people getting usual care. The AQLQ effect appeared to be sustained up to a year after treatment, but due to its low quality this evidence must be interpreted with caution. As asthma exacerbations requiring at least a course of oral steroids were not consistently reported, we could not perform a meta-analysis.Anxiety scores were difficult to pool but showed a benefit of CBT compared with usual care (SMD -0.38, 95% CI -0.73 to -0.03), although this depended on the analysis used. The confidence intervals for the effect on depression scales included no difference between CBT and usual care when measured as change from baseline (SMD -0.33, 95% CI -0.70 to 0.05) or endpoint scores (SMD -0.41, 95% CI -0.87 to 0.05); the same was true for medication adherence (MD -1.40, 95% CI -2.94 to 0.14; participants = 23; studies = 1; I(2) = 0%).Subgroup analyses conducted on the AQLQ outcome did not suggest a clear difference between individual and group CBT, baseline psychological status, or CBT model. The small number of studies and the variation between their designs, populations, and other intervention characteristics limited the conclusions that could be drawn about these possibly moderating factors.The inability to blind participants and investigators to group allocation introduced significant potential bias, and overall we had low confidence in the evidence. AUTHORS' CONCLUSIONS: For adults with persistent asthma, CBT may improve quality of life, asthma control, and anxiety levels compared with usual care. Risks of bias, imprecision of effects, and inconsistency between results reduced our confidence in the results to low, and evidence was lacking regarding the effect of CBT on asthma exacerbations, unscheduled contacts, depression, and medication adherence. There was much variation between studies in how CBT was delivered and what constituted usual care, meaning the most optimal method of CBT delivery, format, and target population requires further investigation. There is currently no evidence for the use of CBT in adolescents with asthma

Promoting Physical Activity in Children with Juvenile Idiopathic Arthritis through an internet-based program: results of a pilot randomized controlled trial.

Promoting Physical Activity in Children With Juvenile Idiopathic Arthritis Through an Internet-Based Program: Results of a Pilot Randomized Controlled Trial OTTO T. H. M. LELIEVELD,1 WINEKE ARMBRUST,2 JAN H. B. GEERTZEN,3 INEZ DE GRAAF,2 MIEK A. VAN LEEUWEN,1 PIETER J. J. SAUER,2 ELLEN VAN WEERT,3 AND JELTE BOUMA4 Objective. Patients with juvenile idiopathic arthritis (JIA) are less physically active than healthy peers. Therefore, we developed an Internet-based intervention to improve physical activity (PA). The aim of this study was to examine the effectiveness of the program in improving PA. Methods. PA was determined by activity-related energy expenditure, PA level, time spent on moderate to vigorous PA, and the number of days with >1 hour of moderate to vigorous activity, and was assessed with a 7-day activity diary. Aerobic exercise capacity was assessed by means of a Bruce treadmill test and was recorded as maximum endurance time. Disease activity was assessed by using the JIA core set. Adherence was electronically monitored. Results. Of 59 patients, 33 eligible patients were included and randomized in an intervention (n _ 17, mean _ SD age 10.6 _ 1.5 years) or control waiting-list group (n _ 16, mean _ SD age 10.8 _ 1.4 years). All patients completed baseline and T1 testing. PA significantly improved in both groups. Maximum endurance time significantly improved in the intervention group but not in the control group. In a subgroup analysis for patients with low PA (intervention: n _ 7, control: n _ 5), PA improved in the intervention group but not in the control group. The intervention was safe, feasible, and showed a good adherence. Conclusion. An Internet-based program for children with JIA ages 8–12 years directed at promoting PA in daily life effectively improves PA in those patients with low PA levels. It is also able to improve endurance and it is safe, feasible, and has good adherence. INTRODUCTION Children and adolescents with juvenile idiopathic arthritis (JIA) have reduced aerobic and anaerobic exercise capacity (1–3). There is also evidence that they are less physically active as compared with healthy peers (4,5). As a result, they may perceive difficulties in joining regular sport activities and in social interaction. It is unclear if this is the cause of the low exercise capacity or the result of it. Physical activity (PA) and physical fitness are interrelated (6). PA can be described as all leisure and non-leisure body movements resulting in an increased energy output from the resting condition (7). To become and remain physically fit, it is necessary to become physically active and to adopt and maintain a physically active lifestyle (8). Evidence is accumulating that PA is effective in the primary and secondary prevention of several chronic conditions (9 –11). PA is also associated with a reduction in all-cause mortality (11). There is evidence that in youth ages 6–16 years, PA controls body weight; reduces blood pressure in hypertensive youth; improves aerobic capacity, muscular strength, endurance, and skeletal health; reduces anxiety and depression; and improves self-concept (12). PA also has a positive effect on academic performance, concentration, memory, and classroom behavior (12). For children with JIA and other chronic diseases, it is recognized that they could take advantage of the same health benefits (13,14). Evidence supports the fact that PA . 1Otto T. H. M. Lelieveld, BSc, Miek A. van Leeuwen, MD, PhD: University Medical Center Groningen, Groningen, The Netherlands; 2Wineke Armbrust, MSc, Inez de Graaf, BSc, Pieter J. J. Sauer, PhD: Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, The Netherlands; 3Jan H. B. Geertzen, MD, PhD, Ellen van Weert, PhD: University Medical Center Groningen and University of Groningen, Groningen, The Netherlands; 4Jelte Bouma, PhD: University of Groningen, Groningen, The Netherlands. Address correspondence to Otto T. H. M. Lelieveld, BSc, Center for Rehabilitation, University Medical Center Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands. E-mail: [email protected]. Submitted for publication September 28, 2009; accepted in revised form January 6, 2010. Arthritis Care & Research Vol. 62, No. 5, May 2010, pp 697–703 DOI 10.1002/acr.20085 © 2010, American College of Rheumatology ORIGINAL ARTICLE 697

Persistent differences in asthma self-efficacy by race, ethnicity, and income in adults with asthma

OBJECTIVE: The objective of this population-based study was to determine if and to what extent there are differences in asthma self-efficacy by race/ethnicity and income, and whether health status, levels of acculturation, and health care factors may explain these differences. METHODS: We conducted a secondary data analysis of asthma self-efficacy using the 2009 and 2011-2012 California Health Interview Survey, in adults with asthma (n = 7874). In order to examine if and how the effect of race /ethnicity and income on asthma self-efficacy may have been altered by health status, acculturation, and health care factors, we used staged multivariable logistic regression models. We conducted mediation analyses to evaluate which of these factors might mediate disparities in self-efficacy by race/ethnicity and income. RESULTS: 69.8% of adults reported having high asthma self-efficacy. Latinos (OR 0.66; 95% CI 0.51–0.86), African-Americans (OR 0.50; 95% CI 0.29–0.83), American Indian/Alaskan Natives (OR 0.55; 95% CI 0.31–0.98), and Asian/Pacific Islanders (OR 0.34; 95% CI 0.23–0.52) were less likely to report high self-efficacy compared to Whites. Individuals with income below the federal poverty level (OR 0.56; 95% CI 0.40-0.78) were less likely to report high self-efficacy compared to higher income individuals. The relationship between income and self-efficacy was no longer significant after further adjustment for health care factors; however, the differences in race and ethnicity persisted. Receiving an asthma management plan mediated the relationship in certain subgroups. CONCLUSIONS: Addressing modifiable health care factors may play an important role in reducing disparities in asthma self-efficacy

Internet Program for Physical Activity and Exercise Capacity in Children With Juvenile Idiopathic Arthritis: A Multicenter Randomized Controlled Trial

Objective. To determine the effects of Rheumates@Work, an internet-based program supplemented with 4 group sessions, aimed at improving physical activity, exercise capacity, health-related quality of life (HRQoL), and participation in children with juvenile idiopathic arthritis. Methods. Patients were recruited from 3 pediatric rheumatology centers in The Netherlands for an observer-blinded, randomized controlled multicenter trial. Physical activity level, time spent in rest, light, and moderate-to-vigorous physical activity (MVPA) were recorded in a diary and with an accelerometer, before intervention, after intervention, and at followup after 3 and 12 months (intervention group only). Exercise capacity was assessed using the Bruce treadmill protocol, HRQoL was assessed with the Pediatric Quality of Life Inventory generic core scale, and participation in school and in physical education classes were assessed by questionnaire. Results. The intervention group consisted of 28 children, and there were 21 children in the control group. MVPA, exercise capacity, and participating in school and physical education classes improved significantly in the intervention group. HRQoL improved in the control group. No significant differences were found between groups. The effect of Rheumates@Work on physical activity and exercise capacity lasted during the 12 months of followup. Improvements in physical activity were significantly better for the cohort starting in winter compared to the summer cohort. Conclusion. Rheumates@Work had a positive, albeit small, effect on physical activity, exercise capacity, and participation in school and physical education class in the intervention group. Improvements lasted for 12 months. Participants who started in winter showed the most improvement. Rheumates@Work had no effect on HRQoL

Predictors of adolescents' health-promoting behaviors guided by primary socialization theory

PURPOSE: The purpose of this study was to determine the influence of parents and peers on adolescents’ health-promoting behaviors, framed by Primary Socialization Theory. DESIGN AND METHOD: Longitudinal data collected annually from 1,081 rural youth (mean age = 17 ±.7; 43.5% males; 44% Hispanic) and once from their parents were analyzed using generalized linear models. RESULTS: Parental monitoring and adolescent’s religious commitment significantly predicted all health-promoting behaviors (nutrition, physical activity, safety, health practices awareness, stress management). Other statistically significant predictors were parent’s responsiveness and health-promoting behaviors. Peer influence predicted safety and stress management. PRACTICE IMPLICATIONS: Nurses may facilitate adolescents’ development of health-promoting behaviors through family-focused interventions