摘要

哮喘是儿童时期最常见的疾病，对居住在城市地区的低收入，少数民族儿童产生不成比例的不良影响。与哮喘发病率和死亡率相关的一系列风险因素例如：治疗的不坚持，暴露于环境触发因素，低收入家庭，暴露于慢性压力，儿童心理问题，父母压力，家庭功能障碍，肥胖症，缺乏身体活动和不健康的饮食。这些风险因素往往具有复杂的相互作用和相互关系。探索这些因素在哮喘发病率和死亡率中的相互关系的综合研究是必要的，并且有助于通知临床干预。大量的研究集中在干预措施，以改善哮喘患者的依从性，哮喘管理，哮喘症状和生活质量。教育干预措施与社会心理干预措施(如行为，认知行为或家庭干预)相结合，对学校，家庭和急诊室提供护理是有益的，可以帮助解决获得儿童和家庭护理的障碍。最近的另外一些研究已经探索了与儿科哮喘患者一起使用多学科协作综合治疗，提供了有希望的结果。综合护理可以理想地处理在儿童哮喘中发挥作用的多种复杂的社会心理和健康因素，增加以患者为中心的护理，并促进协作的患者 - 提供者关系。在这方面的进一步研究是必不可少的，将是有益的。

背景：哮喘是美国儿童中最常见的慢性疾病，估计影响了1060万(14.5%)的儿童[1]，对受影响青年的身心健康产生了重大影响。 小孩的哮喘会给父母和家庭系统带来很大的压力和压力。 大量的研究集中在儿童哮喘，探索疾病危险因素，依从性，儿童和护理人员心理问题的角色，家庭和环境压力因素的影响以及哮喘和肥胖等健康因素之间的关系。 其他研究还探讨了干预措施，以减少哮喘青年的依从性问题，改善整体功能和哮喘管理。

环境风险因素

低收入城市少数民族青年受哮喘影响较大，因此低社会经济地位儿童[2,3]和城市少数民族家庭[3,4]的哮喘患病率和疾病发病率较高。 患病率表明，非裔美国儿童的哮喘发病率高于拉丁裔或白人儿童[2]，波多黎各儿童的哮喘发病率高于其他拉丁裔儿童[3]。 此外，与哮喘白人儿童相比，非裔美国人和拉丁裔哮喘儿童的急诊室访视率和哮喘死亡率更高[5]。 一些研究表明，这些哮喘患病率的种族差异主要出现在低收入青年，而不是中低收入阶层的少数儿童[6]。生活在低收入家庭的儿童往往体验到压力增加，如家庭冲突，暴力，低质量的家庭环境，危险的邻居和污染的空气和水[7]，这被认为是哮喘的危险因素[8]。因此，与住房相关的压力[9]，社区压力源，如高犯罪率[10]，贫穷[11]，慢性家庭压力[12]，暴露于烟草烟雾和污染物[13]等社区压力因素与增加哮喘症状有关。作为解释这种关系的一个途径，暴露于慢性压力与高度炎症反应有关，反过来又与哮喘症状增加有关[12]。

此外，研究发现，居住在低收入家庭的儿童更可能经历父母支持和参与的减少，花更多的时间看电视，更多地感受到他们的生活和生活环境缺乏控制[7]。 来自经济困难家庭的儿童也可能获得照料和较差的照顾质量[14]; 据估计，2-17岁的儿童中有41%没有得到所需的精神卫生服务[1]。 因此，低收入的城市少数儿童已经增加了正确控制哮喘的障碍，包括增加暴露于环境触发因素和减少获得适当治疗的机会[8]。此外，较低的父母教育与哮喘患病率较高，哮喘药物依从性较低以及哮喘住院率较高有关[15]。 由于低收入家庭的父母受教育程度低于高收入家庭的父母，这也可以解释低收入家庭与哮喘之间的关系。

坚持使用哮喘药物

哮喘药物治疗能够减少哮喘发病率，急诊室访视和住院治疗，哮喘控制药物依从性差与哮喘急性加重[16]，哮喘未控制[17,18]，哮喘发病率[19,20]和哮喘死亡率[21]相关。 然而，哮喘控制药物往往在儿童中使用不足[22]，药物不依从是一个重要的问题[23]，特别是在城市微小病患者[22]。 鉴于这些结果，改善药物依从性的干预对于降低哮喘发病率和死亡率是重要的。 此外，改善哮喘药物依从性和随之而来的改善哮喘控制可以导致生活质量的提高[24]。

几个危险因素似乎会破坏儿童服药依从性，包括男性，非亚裔，背景较大，家庭较大，诊断年龄较大[25]，生活在农村[22]，社会经济地位较低[26]， 导致不遵守的因素通常可以分为有意或无意[27]。无意的因素包括导致药物不被人们选择之外的其他原因所吸收的障碍和障碍。 [28]缺乏父母的参与[28]，缺乏适当的药物治疗，不正确的吸入技术[26]，儿童心理障碍[29]，青春期遗忘[30]。 照顾者心理困扰，家庭功能问题[31] ，儿童和家庭对哮喘和哮喘药物的认识不足，症状识别有限，缺乏社区支持[24]。另外，哮喘和哮喘药物对儿童和家庭的不良认知，有限的临床表现以及缺乏社区支持也可能导致药物不依从[24]。故意的因素包括对自己的疾病和药物的信念，导致选择不服用药物[32]。故意的因素，如父母关心控制药物(如副作用，安全性)和治疗费用[33]，青少年的信念，药物是不必要的或无益的[30]已被证明与较高不遵守。

哮喘患儿及其护理人员的心理功能

大多数研究表明，与健康同龄人相比，哮喘患儿表现出更多的行为问题[34]，并使焦虑和情感障碍等疾病内化[35]。哮喘与行为和情绪困难之间的关联已经显示出随着哮喘严重程度的显着增加[34]。 哮喘儿童的这些心理障碍与功能限制增加和哮喘管理较差有关。例如，即使在控制了哮喘严重程度之后，患有并发哮喘和内化障碍的儿童的功能障碍增加[35]，错过上课时间[36]，使用控制药物增加，肺功能较差，出现频率增加 护理使用[37]，以及更高的治疗不依从性，这反过来又与较差的健康结果相关[29]。

小孩的哮喘也会影响护理人员的调节，心理功能和压力感受。哮喘患儿护理人员心理障碍的风险显着增加反映在抑郁[29,38]和焦虑[37]的增加。 哮喘儿童护理人员的这些心理障碍可能会导致哮喘管理方面的问题。例如，父母压力与较差的药物依从性显着相关，母亲的抑郁症状与使用适当的吸入技术，较差的药物依从性，较大的烟草烟雾暴露以及较低的控制其儿童哮喘的能力[39]。

健康和生活方式

最近的研究集中在诸如促进健康或威胁健康的生活方式行为(例如饮食，运动)等健康因素及其与哮喘患者的相关性。调查人员发现儿童人群中肥胖与哮喘之间存在正相关关系[40,41]。儿童和青少年的肥胖也与抑郁和焦虑增加有关[42,43]。 在哮喘患儿中，肥胖已被发现与非受控哮喘[13,44]，哮喘严重程度[41,45]，紧急护理使用和皮质类固醇使用[46]相关。此外，肥胖对哮喘管理提出了挑战，例如对哮喘控制药物的反应性下降和生活质量下降[47]，超重的哮喘儿童与健康体重相比，发现污染物暴露的负面影响增加 哮喘患儿[13]。

哮喘患儿的体力活动水平较低，导致肥胖和心理健康问题。例如，哮喘患儿体力活动水平较低[48,49]，而较高水平的久坐活动参与度，如在计算机上花费的时间[50]。此外，体重超重的哮喘儿童比没有哮喘的超重儿童显着减少体育锻炼的可能性[51]。不活动增加可能导致哮喘和肥胖之间的问题关系。例如，哮喘超重儿童观看电视的时间增加与呼吸系统症状的风险增加有关[52,53]，而体育锻炼的增加与呼吸系统症状的风险降低有关[53]。另外，有人认为体力活动减少导致哮喘发病率增加[54]。此外，数据表明，对于哮喘患儿，身体活动水平与心理健康之间存在正相关关系[48]。

同样，饮食与体重有关，并影响哮喘。大多数吃西式饮食的儿童，其脂肪和加工食品含量较高，而哮喘患病率高于食用较少脂肪和加工食品的儿童[55]。 地中海饮食与哮喘症状减轻有关[56]，建议坚持饮食健康对儿童哮喘有保护作用[57]。饮食与哮喘之间关系的一个可能的解释是饮食对肠内微生物群的影响，进而影响肠内微生物群对免疫炎症反应的影响[58]。

心理干预

对哮喘儿童进行一系列社会心理干预，如教育计划，行为干预，认知行为疗法，家庭干预和/或基于社区的干预。 关于心理干预疗效的研究是有限的，还没有定论[59,60]，并且受到关于方法学问题的担忧的困扰[60]。尽管存在这些问题，初步的证据表明，心理干预可以改善哮喘患儿的生活质量和医疗效果。将教育与社会心理干预相结合的干预措施，如行为，认知行为和/或家庭干预显示出特别的前景[31]。

一些干预措施，如自我管理培训和教育，被认为是哮喘患者在整个治疗过程中治疗的重要组成部分。对这些项目的研究已经发现哮喘患儿有益，包括提高对疾病管理的认识和信心[61,62]，改善依从性[23,63]，改善哮喘症状[64]，改善肺功能[65] 减少急诊室访问[65,66]，减少学校缺勤，减少活动限制[65]，提高生活质量[66]。然而，在获得文化敏感，适龄的患者教育资料方面，全球性差距巨大[67]。

由于担心缺乏有效的干预措施，尤其是处于不利背景的儿童，一些调查人员越来越重视探索以学校为基础的急诊室和家庭教育干预措施。 当这些干预措施包括父母时，结果表明家长对疾病管理的自我效能得到改善[68]。 紧急情况的房间干预与增加的坚持和减少未来的紧急情况访问有关[69]。 另外，研究发现，家庭干预减少了哮喘症状和紧急情况下的访问[70,71]。

尽管有这些结果，但各个研究结果的综合荟萃分析结果显示，没有额外干预措施的教育干预措施对于改善哮喘管理和健康结局是不够的[72]。调查表明，将诸如行为或认知行为干预等社会心理干预措施纳入哮喘教育项目，可减轻哮喘严重程度，减少急诊室访视[73]，减少儿童抑郁症，减轻儿童压力[74]，减少学校缺勤[73]，坚持不懈，减少亲子冲突[75]。同样，教育与家庭治疗相结合，对儿童和父母有益，导致气道炎症减轻，身体健康改善，心理健康得到改善。在哮喘管理和父母焦虑情绪方面，父母也表现出增加的父母效能[76]。此外，一项研究发现，越来越多的父母监督增加了儿童药物的依从性[77]。

对于超重儿科患者，提高干预措施以提高身体活动水平，减少不健康的饮食行为[47]。例如，改善饮食摄入的行为干预导致BMI下降和哮喘改善[78]，包括心理，营养和运动成分在内的干预措施显示BMI降低，哮喘控制改善，肺功能改善[79]。

综合护理

考虑到影响哮喘发作和严重程度的复杂因素，应对这一挑战需要将多个干预措施组合在一起，以满足个别儿童及其家庭的需求。最近的证据表明，全面，协作，多学科护理(称为综合护理)的重要性，除了传统的医疗护理外，还涉及精神健康，患者教育和家庭功能[80]。例如，国立卫生研究院的准则[81]特别强调了对心理并发症，心理社会压力源和治疗不依从的患者采用跨学科方法的益处。世界各地的机构正在努力通过综合护理途径来发展综合护理，以治疗哮喘[82]。因此，哮喘自我管理技能的综合方法，包括社区参与方案设计，并重点关注家庭压力，家庭关系[83,84]，家庭冲突，父母压力，养育方式和儿童行为[ 84]可能对哮喘患儿产生更大的益处和结果。

提供整体护理的综合护理项目已经证明哮喘症状，哮喘管理方面的感知能力，减少皮质类固醇使用以及改善护理人员和儿童的生活质量方面有显着改善[85,86]。特别是侧重于特别解决治疗障碍的干预措施，如电话联系，简单干预措施和父母解决问题，可以显着提高初次任用和继续参与治疗[87]。 这些策略对青少年滥用药物[88,89]，儿童心理健康[90]和注意力缺陷/多动障碍[91]显示出有前景的有效性。

综合护理可以根据患者的需要在多个设置中进行。作为咨询联络服务的一部分，小儿心理学家经常在住院病人或三级护理诊所就诊，但是越来越多地被纳入综合护理小组[80,85]。行为健康从业者可以帮助医疗机构在医疗预约期间实施坚持促进干预[93]。最后，早期干预和预防保健运动[94,95]为初级保健机构[96]和校本保健中心[97,98]提供了多学科干预的机会。由于儿童在学校(通常6-8小时)花费了大量时间，学校为药物管理，父母支持和行为干预提供了独特的机会。基于校园干预的研究已经发现，包括提高知识，自我效能和疾病管理[62]和改善哮喘控制[99]的好处。

结论

一系列环境，社会心理，行为和生活方式风险因素与哮喘恶化和发病率有关。这些风险因素具有复杂的相互作用和双向关系(见图1)。绝大多数的研究集中在孤立的一个或几个这些因素。尽管经常出现这种罕见的焦点，研究中出现的几个风险因素并不罕见，因此不管最初的重点如何，研究结果往往存在一些重叠。例如，对儿童风险因素的研究往往发现养育因素是相关的。鉴于风险因素之间复杂的相互作用，需要综合研究探讨所有或大部分因素在哮喘发病率和死亡率方面的相互关系，并有助于通知临床干预。

因此，需要考虑个人，家族和环境风险因素之间相互作用的综合治疗方法。最近的研究已经强调了多学科，协作，综合护理小儿哮喘患者的重要性，并取得了可喜的成果。 这种全面的方法非常适合解决在儿童哮喘中发挥作用的多种复杂的，相互关联的社会心理和健康/生活方式因素。 这种综合护理方法对于增加以患者为中心的护理，共享决策以及家庭和提供者之间的合作关系也可能是有效的。 这方面的进一步研究是必要的，将是有益的。

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