Leveraging digital health technologies in heart failure self-care interventions to improve health equity.

For patients with heart failure, self-care is crucial, but recommendations for self-care are often not adhered to. Digital health interventions have the potential to help patients improve their self-care and, ultimately, their health outcomes, but without careful examination, digital interventions may generate further inequality. In this study, we use a digital health equity framework to examine challenges and opportunities related to digital health interventions across many domains of influence that may affect health equity. We draw from our own experience in conducting a decentralized clinical trial with multiple sensors and apps to help patients with heart failure improve adherence to key self-care behaviors. Finally, we provide recommendations for leveraging digital health interventions in research and practice to address health equity.

Symptom phenotyping in people with cystic fibrosis during acute pulmonary exacerbations using machine-learning K-means clustering analysis.

INTRODUCTION: People with cystic fibrosis (PwCF) experience frequent symptoms associated with chronic lung disease. A complication of CF is a pulmonary exacerbation (PEx), which is often preceded by an increase in symptoms and a decline in lung function. A symptom cluster is when two or more symptoms co-occur and are related; symptom clusters have contributed meaningful knowledge in other diseases. The purpose of this study is to discover symptom clustering patterns in PwCF during a PEx to illuminate symptom phenotypes and assess differences in recovery from PExs. METHODS: This study was a secondary, longitudinal analysis (N = 72). Participants at least 10 years of age and being treated with intravenous antibiotics for a CF PEx were enrolled in the United States. Symptoms were collected on treatment days 1-21 using the CF Respiratory Symptom Diary (CFRSD)-Chronic Respiratory Symptom Score (CRISS). K-means clustering was computed on day 1 symptom data to detect clustering patterns. Linear regression and multi-level growth models were performed. RESULTS: Symptoms significantly clustered based on severity: low symptom (LS)-phenotype (n = 42), high symptom (HS)-phenotype (n = 30). HS-phenotype had worse symptoms and CRISS scores (p< 0.01) than LS-phenotype. HS-phenotype was associated with spending 5 more nights in the hospital annually (p< 0.01) than LS-phenotype. HS-phenotype had worse symptoms over 21 days than LS-phenotype (p< 0.0001). CONCLUSION: Symptoms significantly cluster on day 1 of a CF-PEx. PwCF with HS-phenotype spend more nights in the hospital and are less likely to experience the same resolution in symptoms by the end of PEx treatment than LS-phenotype.

Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale.

Background: Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. Methods: A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. Results: A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. Conclusion: Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.

Development and Pilot Randomized Trial of a Coping Skills Intervention for Low-SES Latinx Families of Children with Asthma.

Objective: Psychosocial stress contributes to asthma disparities for low-SES Latinx children, but primary and secondary control coping by children and parents is associated with better psychosocial and asthma outcomes. Therefore, we developed and pilot tested Adapt 2 Asthma (A2A), a family-based coping and asthma self-management intervention for low-SES Latinx families. Methods: Children, parents, and primary care providers (N=16) participated in five focus groups to refine A2A's content and delivery. Subsequently, families of children ages 9-12 with asthma (N=24) were recruited from primary care clinics and randomly assigned to receive A2A or enhanced usual care (EUC). Results: Based on focus groups, A2A was refined to address feasibility, Latinx-specific cultural factors, and provider-family gaps. Results of the pilot RCT showed that 92% of families completed all sessions of A2A, and there were high levels of satisfaction with and fidelity to A2A. There were no statistically significant differences between the A2A and EUC groups at 3-month follow-up, although there were small, non-significant effects favoring A2A on parent-reported asthma control, parent secondary control coping, and emergency department visits. Conclusions: We found evidence of acceptability, feasibility, and potential benefits of A2A for low-SES Latinx families. Findings provide guidance for future implementation in primary care.

Internet Use Behavior Among Adolescents and Young Adults with Chronic Illnesses.

PURPOSE: Approximately 25% of adolescents and young adults (AYA) have special healthcare needs. Transitioning from a pediatric to an adult model of healthcare is an important event but most AYA with special health care needs and their families do not receive the preparation and support they need to transition to adult care. The purpose of this scoping review was to determine how AYA use the internet for health-related information. METHODS: Three databases were used CINAHL, Medline and PsycINFO with search terms including adolescent, young adult, chronic illness, internet, social media. Inclusion criteria were articles focused on AYA (16-25), use of internet or social media for health-related information, published in English between 2005 and 2020. Initial search yielded 369 articles, 335 were eliminated as not meeting the inclusion criteria. FINDINGS: Of the 34 remaining, 14 were eligible for inclusion. AYA used the internet for health concerns, socializing, entertainment, homework, general information, and shopping. AYA expressed concerns about disclosing personal health information and potential misinformation on websites. Few used it to look up their diagnosed condition or talk to illness peers. AYA report they also get information from non-internet sources like providers, parents, and peers. CONCLUSIONS: AYA have a need for health-related information. When planning online resources critical issues include perceived threats to privacy and security and quality of information. Online resources must address these issues so AYA consumers can have confidence in their website.

Distribution of SARS-CoV-2 RNA signal in a home with COVID-19 positive occupants.

Although many COVID-19 patients isolate and recover at home, the dispersal of SARS-CoV-2 onto surfaces and dust within the home environment remains poorly understood. To investigate the distribution and persistence of SARS-CoV-2 in a home with COVID-19 positive occupants, samples were collected from a household with two confirmed COVID-19 cases (one adult and one child). Home surface swab and dust samples were collected two months after symptom onset (and one month after symptom resolution) in the household. The strength of the SARS-CoV-2 molecular signal in fomites varied as a function of sample location, surface material and cleaning practices. Notably, the SARS-CoV-2 RNA signal was detected at several locations throughout the household although cleaning appears to have attenuated the signal on many surfaces. Of the 24 surfaces sampled, 46% were SARS-CoV-2 positive at the time of sampling. The SARS-CoV-2 concentrations in dust recovered from floor and HVAC filter samples ranged from 104 to 105 N2 gene copies/g dust. While detection of viral RNA does not imply infectivity, this study confirms that the SARS-CoV-2 RNA signal can be detected at several locations within a COVID-19 isolation home and can persist after symptoms have resolved. In addition, the concentration of SARS-CoV-2 (normalized per unit mass of dust) recovered in home HVAC filters may prove useful for estimating SARS-CoV-2 airborne levels in homes. In this work, using the quantitative filter forensics methodology, we estimated an average integrated airborne SARS-CoV-2 concentration of 69 ± 43 copies/m3. This approach can be used to help building scientists and engineers develop best practices in homes with COVID-19 positive occupants.

Examining Social Determinants of Health in Childhood Asthma Management.

PURPOSE: Social determinants of health (SDoHs) influence how well a family manages children's asthma. The aim of this study was to examine the influence of SDoHs on family asthma management. DESIGN: A cross-sectional exploratory study was conducted with 292 children in grades 2 to 5 who had current asthma and their parents to examine associations between SDoHs and the families' asthma management, quality of life, and healthcare utilization. METHODS: Data were collected from both child and parent. Social determinants of health include the child's race/ethnic group, age, gender, and asthma severity and the family's socioeconomic status and language spoken in the home, and the school was the community-level variable. Parents and children completed asthma management and quality-of-life scales and parents reported on the children's emergency department visits and hospitalizations for asthma. RESULTS: Worse quality of life was reported by families with lower socioeconomic status and African American children. Asthma severity was associated with parents' asthma management but not children's asthma self-management. Families who spoke Spanish at home had the lowest socioeconomic status yet performed significantly more asthma management than English-speaking families. CONCLUSIONS: The findings highlight factors the clinical nurse specialist should address in educational interventions.

Phthalates and organophosphates in settled dust and HVAC filter dust of U.S. low-income homes: Association with season, building characteristics, and childhood asthma.

Phthalates and organophosphates are ubiquitous indoor semi-volatile organic contaminants (SVOCs) that have been widely used as plasticizers and flame retardants in consumer products. Although many studies have assessed their levels in house dust, only a few used dust samples captured by filters of building heating, ventilation, and air conditioning (HVAC) systems. HVAC filters collect particles from large volumes of air over a long period of time (potentially known) and thus provide a spatially and temporally integrated concentration. This study measured concentrations of phthalates and organophosphates in HVAC filter dust and settled floor dust collected from low-income homes in Texas, United States, in both the summer and winter seasons. The most frequently detected compounds were benzyl butyl phthalate (BBzP), di-(2-ethylhexyl) phthalate (DEHP), di-n-octyl phthalate (DnOP), tris (1-chloro-2-propyl) phosphate (TCIPP), triphenyl phosphate (TPHP), and tris (1,3-dichloroisopropyl) phosphate (TDCIPP). The median level of TCIPP in settled dust was 3- to 180-times higher than levels reported in other studies of residential homes. Significantly higher concentrations were observed in HVAC filter dust as compared to settled dust for most of the frequently detected compounds in both seasons, except for several phthalates in the winter. SVOC concentrations in settled dust in winter were generally higher than in summer, while different seasonality patterns were found for HVAC filter dust. Settled dust samples from homes with vinyl flooring contained significantly higher levels of BBzP and DEHP as compared to homes with other types of floor material. The concentration of DEHP and TDCIPP in settled dust also significantly associated with the presence of carpet in homes. Cleaning activities to remove dust from furniture actually increased the levels of certain compounds in HVAC filter dust, while frequent vacuuming of carpet helped to decrease the concentrations of some compounds in settled dust. Additionally, the size and age of a given house also correlated with the levels of some pollutants in dust. A statistically significant association between DEHP concentration in HVAC filter dust in summer and the severity of asthma in children was observed. These results suggest that HVAC filter dust represents a useful sampling medium to monitor indoor SVOC concentrations with high sensitivity; in contrast, when using settled dust, in addition to consideration of seasonal influences, it is critical to know the sampling location because the type and level of SVOCs may be related to local materials used there.

Feasibility study of a combined lifestyle behaviors and asthma self-management intervention for school-aged children.

PURPOSE: The purpose of this study is to test the feasibility of delivering an intervention that combines healthy lifestyle behaviors related to weight management with asthma self-management, the Living Healthy with Asthma intervention, to children who have asthma. METHODS AND DESIGN: Using a mixed design, the feasibility study of the 12-week Living Healthy with Asthma intervention was conducted with a single group of children diagnosed with asthma. Pretest and posttest data were collected on asthma-related (self-management, metered dose inhaler [MDI] skill, asthma severity, quality of life [QOL]), and healthy lifestyle variables (body mass index [BMI], dietary quality). A matched comparison sample was drawn from a separate study that tested the same asthma self-management component (single intervention) used in the feasibility study to determine if the Living Healthy with Asthma intervention worked as well as the single intervention for improving children's asthma self-management. RESULTS: Thirteen school-aged children were enrolled in the feasibility study. There were significant reductions in BMI z-scores (P = 0.007), and improvements in vegetable servings (P = 0.03), MDI skill (P = 0.005), children's QOL (P < 0.001), and parents' QOL (P = 0.03). When comparing the feasibility group with the matched comparison group (n = 13), there were no significant differences in asthma self-management, MDI skill, or asthma severity after the interventions. PRACTICE IMPLICATIONS: Findings supported the feasibility of implementing the combined intervention, and it was not inferior to the single intervention-which supports nurses' efforts to help families manage multiple health problems.

Filter forensics: microbiota recovery from residential HVAC filters.

BACKGROUND: Establishing reliable methods for assessing the microbiome within the built environment is critical for understanding the impact of biological exposures on human health. High-throughput DNA sequencing of dust samples provides valuable insights into the microbiome present in human-occupied spaces. However, the effect that different sampling methods have on the microbial community recovered from dust samples is not well understood across sample types. Heating, ventilation, and air conditioning (HVAC) filters hold promise as long-term, spatially integrated, high volume samplers to characterize the airborne microbiome in homes and other climate-controlled spaces. In this study, the effect that dust recovery method (i.e., cut and elution, swabbing, or vacuuming) has on the microbial community structure, membership, and repeatability inferred by Illumina sequencing was evaluated. RESULTS: The results indicate that vacuum samples captured higher quantities of total, bacterial, and fungal DNA than swab or cut samples. Repeated swab and vacuum samples collected from the same filter were less variable than cut samples with respect to both quantitative DNA recovery and bacterial community structure. Vacuum samples captured substantially greater bacterial diversity than the other methods, whereas fungal diversity was similar across all three methods. Vacuum and swab samples of HVAC filter dust were repeatable and generally superior to cut samples. Nevertheless, the contribution of environmental and human sources to the bacterial and fungal communities recovered via each sampling method was generally consistent across the methods investigated. CONCLUSIONS: Dust recovery methodologies have been shown to affect the recovery, repeatability, structure, and membership of microbial communities recovered from dust samples in the built environment. The results of this study are directly applicable to indoor microbiota studies utilizing the filter forensics approach. More broadly, this study provides a better understanding of the microbial community variability attributable to sampling methodology and helps inform interpretation of data collected from other types of dust samples collected from indoor environments.

Enhancing Asthma Self-Management in Rural School-Aged Children: A Randomized Controlled Trial.

PURPOSE: To test the effects of 2 modes of delivering an asthma educational intervention on health outcomes and asthma self-management in school-aged children who live in rural areas. METHODS: Longitudinal design with data collected 4 times over 12 months. The target sample was composed of children in grades 2-5 who had a provider diagnosis of asthma. Elementary schools were stratified into high or low socioeconomic status based on student enrollment in the free or reduced-cost lunch program. Schools were then randomly assigned to 1 of 3 treatment arms: in-school asthma class, asthma day camp, or the attention-control group. FINDINGS: Sample retention was good (87.7%) and equally distributed by study arm. Improvements in emergency department visits and office visits were related to attending either the asthma class or asthma day camp. Asthma severity significantly decreased in both asthma treatment groups. Other factors such as hospitalizations, parent asthma management, and child asthma management improved for all groups. CONCLUSIONS: Both asthma class and asthma day camp yielded significant reductions in asthma severity. There were reductions in the emergency department and office visits for the 2 asthma arms, and hospitalizations declined significantly for all groups. Asthma self-management also improved in all groups, while it was somewhat higher in the asthma arms. This may be due to the attention being drawn to asthma management by study participation and the action of completing questionnaires about asthma management, asthma symptoms, and health outcomes.

A primary care intervention to improve weight in obese children: A feasibility study.

PURPOSE: Examine the effects of a primary care weight management program, which used a parent-child-provider collaborative negotiation intervention, among rural-dwelling families with obese children. DATA SOURCES: Health histories, physical examinations, fasting blood samples, interviews, and questionnaires. CONCLUSIONS: Feasibility of implementing a family weight management intervention in a rural primary care setting was demonstrated. Few differences between the treatment and comparison groups were found; however, more favorable trends and outcomes occurred in those who received the intervention. IMPLICATIONS FOR PRACTICE: Positive provider-patient communication in helping families with obese children make difficult lifestyle changes should be encouraged in primary care clinics as small changes in behavior can result in reducing risk and improving health outcomes.

Home-based diabetes symptom self-management education for Mexican Americans with type 2 diabetes.

This pilot study evaluated an innovative diabetes symptom awareness and self-management educational program for Mexican Americans, a fast growing minority population experiencing a diabetes epidemic. Patients with diabetes need assistance interpreting and managing symptoms, which are often annoying and potentially life-threatening. A repeated measures randomized controlled trial was conducted with 72 Mexican Americans aged 25-75 years with type 2 diabetes. Experimental condition participants received eight weekly, in-home, one-on-one educational and behavior modification sessions with a registered nurse focusing on symptom awareness, glucose self-testing and appropriate treatments, followed by eight biweekly support telephone sessions. Wait-listed control condition participants served as comparisons at three time points. Hierarchical linear modeling was used to evaluate the effects of the intervention between- and within groups on psychosocial, behavioral and clinical outcomes. Participants were predominantly female, middle-aged, moderately acculturated and in poor glycemic control. Experimental group participants (n = 39) significantly improved glycemic control, blood pressure, symptoms, knowledge, self-efficacy, empowerment and quality of life. Post intervention focus groups reported satisfaction with the symptom focus. Addressing symptoms led to clinical and psychosocial improvements. Symptoms seem to be an important motivator and a useful prompt to engage patients in diabetes self-management behaviors to relieve symptoms and prevent complications.