Self-management of cystic fibrosis: a structural model for educational and behavioral variables

Modelling Successful Self-Management in Adults With Cystic Fibrosis: Vicarious Self-Efficacy From Videos of ‘People Like Me’

Background

Self-efficacy is an important determinant of treatment adherence, and peer modelling of success can provide vicarious self-efficacy. A series of patient stories (‘talking heads’ videos) were developed with people with cystic fibrosis (CF) as part of the CFHealthHub multi-component adherence intervention, aiming to demonstrate success with daily therapy in ‘people like me’.

Methodology

One-to-one semi-structured interviews exploring patients’ experiences, barriers and facilitators of nebuliser adherence were audio and video-recorded between October 2015 and August 2016. Interview transcripts were reviewed to identify descriptions of problem-solving and sustained treatment success. Positive stories potentially providing vicarious descriptions of success were selected as video clips.

Results

In total, 14 adults with CF were recruited from five UK CF centres. Each participant contributed a median of five (interquartile range: 3-6) video clips, and a total of 57 unique clips were uploaded onto the CFHealthHub digital platform. Nine of those clips spanned two categories, hence, there were 66 clips across 16 categories.

Conclusions

The videos were well received though some adults were concerned that comparisons with peers might create anxiety by highlighting the possibility of future decline or current relative underperformance. It is important to sensitively support choice when providing resources aiming to increase vicarious self-efficacy. Our experience may guide the development of similar videos for people with other long-term conditions.

Investigating self-efficacy, disease knowledge and adherence to treatment in adolescents with cystic fibrosis

AIM

Patient adherence is integral to the effectiveness of prescribed treatment, and is associated with beneficial disease outcomes, yet in adolescents with cystic fibrosis, adherence is often sub-optimal. Multiple factors may contribute to treatment adherence, including disease knowledge and self-efficacy. In adolescents with cystic fibrosis: (i) to compare the disease knowledge of adolescents and their parents before transition to adult care; (ii) to determine the relationship between disease knowledge (adolescent, parent) and adherence; and (iii) to evaluate self-efficacy and its association with disease knowledge and adherence.

METHODS

Adolescents with cystic fibrosis and their parents were recruited from a tertiary children's hospital. Disease knowledge and self-efficacy was assessed using the Knowledge of Disease Management-CF and General Self-Efficacy Scales respectively. Using pharmacy records, medication possession ratio was calculated to measure treatment adherence in the preceding year.

RESULTS

Thirty-nine adolescent (aged 12-17 (median 14) years) and parent pairs were recruited. Adherence to hypertonic saline, but not other medications, was significantly associated with disease knowledge in adolescents (r ²  = 0.40, P = 0.029). Mean (SD) adolescent self-efficacy was 30.8 (4.0), and not associated with disease knowledge or adherence. Mean (SD) disease knowledge was less in adolescents than parents (55 (16)% and 72 (14)% respectively, P < 0.001).

CONCLUSION

Disease knowledge is sub-optimal in adolescents with cystic fibrosis, even in the 2 years immediately before transition to adult care. Given that adherence with some treatments has been associated with disease knowledge our results suggest the need for educational interventions in adolescents with cystic fibrosis to optimise self-management and health outcomes.

Psychosocial Challenges/Transition to Adulthood

Advances in the health care of individuals with cystic fibrosis have resulted in more than half of the population older than the age of 18 living longer, fuller lives. This success brings about the need for new areas of improvement and development including the mastery of transitioning from pediatric to adult health care and attention to psychosocial needs. This article reviews key components of the process of transitioning to adult care and some important psychosocial considerations.

Chronic Disease Self-Management by People With HIV

As HIV has transitioned into a chronic disease, reappraisal of clinical management has occurred with chronic disease self-management (CDSM) as one possibility. However, despite extensive work on CDSM across a range of diseases, little attention has focused on psychosocial contexts of the lives of people for whom programs are intended. This article reports semi-structured interviews used to explore health practices and motivations of 33 people with HIV (PWHIV) in Australia. Within participants' accounts, different forms of subjectivity and agency emerged with implications for how they understood and valued health-related behaviors. Four themes arose: health support and disclosure, social support and stigma, employment/structure, and health decisions beyond HIV. The experience of stigma and its intersection with CDSM remains relatively un-chartered. This study found stigma shapes agency and engagement with health. Decisions concerning health behaviors are often driven by perceived social and emotional benefit embedded in concerns of disclosure and stigma.

Self-management education for cystic fibrosis

BACKGROUND

Self-management education may help patients with cystic fibrosis and their families to choose, monitor and adjust treatment requirements for their illness, and also to manage the effects of illness on their lives. Although self-management education interventions have been developed for cystic fibrosis, no previous systematic review of the evidence of effectiveness of these interventions has been conducted.

OBJECTIVES

To assess the effects of self-management education interventions on improving health outcomes for patients with cystic fibrosis and their caregivers

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register (date of the last search: 22 August 2013).We also searched databases through EBSCO (CINAHL; Psychological and Behavioural Sciences Collection; PsychInfo; SocINDEX) and Elsevier (Embase) and handsearched relevant journals and conference proceedings (date of the last searches: 01 February 2014 ).

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials or controlled clinical trials comparing different types of self-management education for cystic fibrosis or comparing self-management education with standard care or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias. Three authors extracted data.

MAIN RESULTS

Four trials (involving a total of 269 participants) were included. The participants were children with cystic fibrosis and their parents or caregivers in three trials and adults with cystic fibrosis in one trial. The trials compared four different self-management education interventions versus standard treatment: (1) a training programme for managing cystic fibrosis in general; (2) education specific to aerosol and airway clearance treatments; (3) disease-specific nutrition education; and (4) general and disease-specific nutrition education. Training children to manage cystic fibrosis in general had no statistically significant effects on weight after six to eight weeks, mean difference -7.74 lb (i.e. 3.51 kg) (95% confidence interval -35.18 to 19.70). General and disease-specific nutrition education for adults had no statistically significant effects on: pulmonary function (forced expiratory volume at one second), mean difference -5.00 % (95% confidence interval -18.10 to 8.10) at six months and mean difference -5.50 % (95% confidence interval -18.46 to 7.46) at 12 months; or weight, mean difference - 0.70 kg (95% confidence interval -6.58 to 5.18) at six months and mean difference -0.70 kg (95% confidence interval -6.62 to 5.22) at 12 months; or dietary fat intake scores, mean difference 1.60 (85% confidence interval -2.90 to 6.10) at six months and mean difference 0.20 (95% confidence interval -4.08 to 4.48) at 12 months. There is some limited evidence to suggest that self-management education may improve knowledge in patients with cystic fibrosis but not in parents or caregivers. There is also some limited evidence to suggest that self-management education may result in positively changing a small number of behaviours in both patients and caregivers.

AUTHORS' CONCLUSIONS

The available evidence from this review is of insufficient quantity and quality to draw any firm conclusions about the effects of self-management education for cystic fibrosis. Further trials are needed to investigate the effects of self-management education on a range of clinical and behavioural outcomes in children, adolescents and adults with cystic fibrosis and their caregivers.

Managing treatment complexity in cystic fibrosis: challenges and opportunities

Cystic fibrosis (CF) is a complex, chronic, multisystem disease for which there is currently no cure. Nonetheless, advances in management have led to dramatic improvements in patient survival. With this development, new issues have arisen for CF patients and their care providers, including an increased symptom burden and increased frequency of co-morbidities as patients reach older ages, leading to the need for a highly complicated and time-consuming regimen of treatments. Such high symptom and treatment burden often leads to non-adherence and low levels of competence with administration of therapy, both of which may have detrimental impacts on CF outcomes. Optimal management is also hindered by other patient-related factors, including inadequacies in disease education which may lead to issues with self-management. This is particularly important during the transition from parent-directed therapy to independent self-management that occurs during adolescence and early adulthood. Clinicians are also faced with a considerable challenge when selecting interventions for individual patients; although the paradigm of aggressive care necessitates a wide range of therapies, there is a limited evidence base with which to compare available therapeutic regimens. Novel pharmacological agents are being developed to target the underlying cause of CF, while non-pharmacological interventions aim to improve competence and maximize adherence and health outcomes. Comparative effectiveness research is needed to simplify management and facilitate the implementation of appropriate treatment strategies.

Relationship of adherence determinants and parental spirituality in cystic fibrosis

The course of cystic fibrosis (CF) progression in children is affected by parent adherence to treatment plans. The Theory of Reasoned Action (TRA) posits that intentions are the best behavioral predictors and that intentions reasonably follow from beliefs ("determinants"). Determinants are affected by multiple "background factors," including spirituality. This study's purpose was to understand whether two parental adherence determinants (attitude towards treatment and self-efficacy) were associated with spirituality (religious coping and sanctification of the body). We hypothesized that parents' attitudes toward treatment adherence are associated with these spiritual constructs. A convenience sample of parents of children with CF aged 3-12 years (n = 28) participated by completing surveys of adherence and spirituality during a regular outpatient clinic visit. Type and degree of religious coping was examined using principal component analysis. Adherence measures were compared based on religious coping styles and sanctification of the body using unpaired t-tests. Collaborative religious coping was associated with higher self-efficacy for completing airway clearance (M = 1070.8; SD = 35.8; P = 0.012), for completing aerosolized medication administration (M = 1077.1; SD = 37.4; P = 0.018), and for attitude towards treatment utility (M = 38.8; SD = 2.36; P = 0.038). Parents who attributed sacred qualities to their child's body (e.g., "blessed" or "miraculous") had higher mean scores for self-efficacy (airway clearance, M = 1058.6; SD = 37.7; P = 0.023; aerosols M = 1070.8; SD = 41.6; P = 0.020). Parents for whom God was manifested in their child's body (e.g., "My child's body is created in God's image") had higher mean scores for self-efficacy for airway clearance (M = 1056.4; SD = 59.0; P = 0.039), aerosolized medications (M = 1068.8; SD = 42.6; P = 0.033) and treatment utility (M = 38.8; SD = 2.4; P = 0.025). Spiritual constructs show promising significance and are currently undervalued in chronic disease management.

Self-management education for cystic fibrosis

BACKGROUND

Self-management education may help patients with cystic fibrosis and their families to choose, monitor and adjust treatment requirements for their illness, and also to manage the effects of illness on their lives. Although self-management education interventions have been developed for cystic fibrosis, no previous systematic review of the evidence of effectiveness of these interventions has been conducted.

OBJECTIVES

To assess the effects of self-management education interventions on improving health outcomes for patients with cystic fibrosis and their caregivers

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register (date of the last search: 23 February 2011).We also searched databases through EBSCO (CINAHL; Psychological and Behavioural Sciences Collection; PsychInfo; SocINDEX) and Elsevier (EMBASE) and handsearched relevant journals and conference proceedings (date of the last searches: 30th March 2011).

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials or controlled clinical trials comparing different types of self-management education for cystic fibrosis or comparing self-management education with standard care or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias. Three authors extracted data.

MAIN RESULTS

Four trials (involving a total of 269 participants) were included. The participants were children with cystic fibrosis and their parents or caregivers in three trials and adults with cystic fibrosis in one trial. The trials compared four different self-management education interventions versus standard treatment: (1) a training programme for managing cystic fibrosis in general; (2) education specific to aerosol and airway clearance treatments; (3) disease-specific nutrition education; and (4) general and disease-specific nutrition education. Training children to manage cystic fibrosis in general had no statistically significant effects on weight after six to eight weeks, mean difference -7.74 lb (95% confidence interval -35.18 to 19.70). General and disease-specific nutrition education for adults had no statistically significant effects on: pulmonary function (forced expiratory volume at one second), mean difference -5.00 % (95% confidence interval -18.10 to 8.10) at six months and mean difference -5.50 % (95% confidence interval -18.46 to 7.46) at 12 months; or weight, mean difference - 0.70 kg (95% confidence interval -6.58 to 5.18) at six months and mean difference -0.70 kg (95% confidence interval -6.62 to 5.22) at 12 months; or dietary fat intake scores, mean difference 1.60 (85% confidence interval -2.90 to 6.10) at six months and mean difference 0.20 (95% confidence interval -4.08 to 4.48) at 12 months. There is some limited evidence to suggest that self-management education may improve knowledge in patients with cystic fibrosis but not in parents or caregivers. There is also some limited evidence to suggest that self-management education may result in positively changing a small number of behaviours in both patients and caregivers.

AUTHORS' CONCLUSIONS

The available evidence from this review is of insufficient quantity and quality to draw any firm conclusions about the effects of self-management education for cystic fibrosis. Further trials are needed to investigate the effects of self-management education on a range of clinical and behavioural outcomes in children, adolescents and adults with cystic fibrosis and their caregivers.

Self-management of older adolescents with inflammatory bowel disease: a pilot study of behavior and knowledge as prelude to transition

OBJECTIVE

Patients gradually assume responsibility for self-management. This study sought to determine whether adolescents with inflammatory bowel disease (IBD) have developed key skills of self-management prior to the age at which many transfer to adult care.

PATIENTS AND METHODS

Adolescents aged 16 to 18 years old in the Children's Hospital Boston IBD database (94 total) received a mailed survey assessing knowledge and confidence of their own health information and behaviors.

RESULTS

Respondents (43%) could name medication and dose with confidence but had very poor knowledge of important side effects. Most patients deferred responsibility mostly or completely to parents for scheduling appointments (85%), requesting refills (75%), or contacting provider between visits (74%).

CONCLUSIONS

Older adolescents with IBD have good recall of medications but not of side effects. Parents remain responsible for the majority of tasks related to clinic visits and the acquisition of medications.

Self-care and cystic fibrosis: a review of research with adults

The issue of self-care is becoming increasingly central to both policy and practice in health and social care in the community. It is imperative therefore that research in this important area is drawn together and presented coherently so as to ensure that change can be informed by evidence and implemented sensitively. As cystic fibrosis (CF) has until recently been regarded as a paediatric condition, there is relatively little research that focuses on the self-care of adults. Although not entirely uncritical of traditional biomedicine, these studies focus on individual patient deficits and are directed primarily at facilitating their 'compliance'. After discussing some important methodological, evidential and theoretical limitations of this research, other recent CF literature will be considered that suggests the possibility of developing a 'social model' for self-care research. The proposed model is more pluralistic and less prescriptive than its predecessors and the resulting 'types' of self-care indicate that both old and new, mainstream and marginal discourses should co-exist. Indeed, recognising the legitimacy of distinct varieties of self-care not only guards against unwarranted moralising and pathologising but may also enable self-care support to be negotiated and tailored more appropriately.

Development, validation, and implementation of a questionnaire assessing disease knowledge and understanding in adult cystic fibrosis patients

BACKGROUND

The number of adults living with cystic fibrosis (CF) is increasing, necessitating an assessment of knowledge in this growing population.

METHODS

A questionnaire assessing CF knowledge was completed by 100 CF patients (median age: 26.0 years, range 17-49 years; median FEV₁: 57.0% predicted, range 20-127% predicted). Level of knowledge was correlated with clinical and sociodemographic characteristics.

RESULTS

Questionnaire validation showed acceptable internal consistency (α=0.75) and test-retest reliability (0.94). Patients had fair overall understanding of CF (mean=72.4%, SD=13.1), with greater knowledge of lung and gastrointestinal topics (mean=81.6%, SD=11.6) than reproduction and genetics topics (mean=57.9%, SD=24.1). Females and those with post-secondary education scored significantly higher (p<0.05).

CONCLUSIONS

This study validated a questionnaire that can be utilized to assess CF knowledge. Although CF patients understand most aspects of their disease, knowledge deficits are common - particularly regarding genetics and reproduction - and should be considered when developing CF education programs.

Adherence to nebulised antibiotics in cystic fibrosis

OBJECTIVE

To examine the adherence of patients with cystic fibrosis to nebulised antibiotics.

METHODS

A longitudinal design with adherence data collected over 12 weeks. 38 patients (mean age 24.6 years, S.D. 5.3) were recruited from an adult cystic fibrosis (CF) clinic. Adherence was electronically monitored using a Prodose adaptive aerosol delivery (AAD) device.

RESULTS

Three indices of adherence were calculated: mean percentage of times the nebuliser was used as prescribed was 50.0% (S.D.=39.7, range 1.1, 155.6); mean percentage of days fully adhered was 31.6% (S.D.=29.4, range 0, 97.2); mean percentage of days nebuliser used at least once was 57.1% (S.D.=34.2, range 3.3, 100).

CONCLUSION

Rates of adherence were generally low. Adherence was not associated with any variables apart from age. There were wide variations between individuals, and differences in rates of adherence depending on how this was defined, with potentially important health consequences for the patients.

PRACTICE IMPLICATIONS

Technology that improves medication administration may still be associated with low rates of adherence. Health professionals need to be mindful of the pattern of non-adherence for each individual, and factors which may be influencing this.

Exploring one's own human condition: adults affected by cystic fibrosis

Drawing on a sample of 11 interviews in France with adults affected by cystic fibrosis, and applying grounded-theory analysis, I describe illness-related learning processes in the case of persons affected by a genetic disorder with early onset. Three outcomes might be of interest to health professionals. First, the diagnosis of genetic disease does not imply that the patients consider themselves to be ill. The meaning of being affected by a genetic disorder has to be understood. Second, these patients gain a particular knowledge of their illness that helps them undertake or avoid certain actions to achieve goals they consider important, through a process I call "critical internalization." Third, these patients exhibit similarities with Freidson's classical medical practitioner's clinical mind, although health is not at all their main priority.

Barriers to self-management and quality-of-life outcomes in seniors with multimorbidities

PURPOSE

Persons with multiple chronic diseases must integrate self-management tasks for potentially interacting conditions to attain desired clinical outcomes. Our goal was to identify barriers to self-management that were associated with lower perceived health status and, secondarily, with lower reported physical functioning for a population of seniors with multimorbidities.

METHODS

We conducted a cross-sectional telephone survey of 352 health maintenance organization members aged 65 years or older with, at a minimum, coexisting diagnoses of diabetes, depression, and osteoarthritis. Validated questions were based on previous qualitative interviews that had elicited potential barriers to the self-management process for persons with multimorbidities. We analyzed associations between morbidity burden, potential barriers to self-management, and the 2 outcomes using multivariate linear regression modeling.

RESULTS

Our response rate was 47%. Sixty-six percent of respondents were female; 55% were aged 65 to 74 years, and 45% were aged 75 years or older. Fifty percent reported fair or poor health. On average they had 8.7 chronic diseases. In multivariate analysis, higher level of morbidity, lower level of physical functioning, less knowledge about medical conditions, less social activity, persistent depressive symptoms, greater financial constraints, and male sex were associated with lower perceived health status. Potential barriers to self-management significantly associated with lower levels of physical functioning were higher level of morbidity, greater financial constraints, greater number of compound effects of conditions, persistent depressive symptoms, higher level of patient-clinician communication, and lower income.

CONCLUSIONS

In addition to morbidity burden, specific psychosocial factors are independently associated with lower reported health status and lower reported physical functioning in seniors with multimorbidities. Many factors are amenable to intervention to improve health outcomes.

Family-Focused Oncology Nursing Research

PURPOSE/OBJECTIVES

To analyze five common assumptions about a family's adjustment to breast cancer and to suggest needed future directions for family-focused research.

DATA SOURCES

Published research in nursing, psychiatry, behavioral medicine, and psycho-oncology about families' functioning with breast cancer.

DATA SYNTHESIS

Evidence from published research is that family members do not modify their coping behavior in response to illness-related pressures, do not appear to learn over time how to manage illness-related concerns, are not responsive to each other's thoughts and feelings about cancer, experience tension in the marriage from cancer, and neither understand nor assist children affected by a mother's breast cancer.

CONCLUSIONS

Current assumptions about how families function with breast cancer need to be replaced with a more informed, data-based view that guides the development of better programs and services for assisting families.

IMPLICATIONS FOR NURSING

Future research and interventions need to address the impact of breast cancer on the primary relationships in a household, the impact of the illness on the family's core functions, and the family members' competencies to manage the illness.

Benefits of an education programme on the self-management of aerosol and airway clearance treatments for children with cystic fibrosis

Adherence to recommended aerosol medicines and airway clearance techniques (ACT) for children with cystic fibrosis (CF) requires self-management skills. A multi-centre, randomized, controlled trial was conducted to investigate the effectiveness of a self-management education programme called 'Airways' for six- to 11-year old children with CF and their caregivers. Assessments were conducted immediately before and after the intervention period, and six and 12 months after the post-intervention assessment. The pen and paper education programme was completed by the child and caregiver together at home. Participants in the intervention and control groups had similar baseline characteristics. A per-protocol analysis was conducted and for variables that changed significantly, an additional intention-to-treat analysis was performed that included data from participants in the intervention group who withdrew from the study during the intervention period. The intervention group increased the percentage of prescribed aerosols taken (P < 0.001) and this was maintained at 12-month follow-up (P < 0.001). There was no change in the percentage of prescribed ACT performed, although when the child was unwell, caregivers in the intervention group increased the frequency and/or duration of ACT (P = 0.028) in the per-protocol analysis but not in the intention-to-treat analysis. Children in the intervention group increased their knowledge of ACT (P < 0.001) which was maintained at 12-month follow-up (P < 0.001) and felt more positively about their chest treatment regimens immediately following the intervention (P = 0.017) but not at 12-month follow-up. There were no significant changes in the control group for these variables over time. No significant changes occurred in the caregivers' reports of self-management behaviours and self-efficacy in either group. The positive results suggest that 'Airways' is a valuable educational tool for primary school-aged children with CF and their caregiver.

Models and theories in studies on educating and counseling children about physical health: a systematic review

The aim of this review is to gain a comprehensive view on the theories and models referred to in studies on educating and counseling children about physical health. A computer search was conducted using PubMed Medline, and Silverplatter Webspirs Psycinfo. Original studies, reviews, and theoretical papers published between 1992-2003 were included. The review presents the results of the 35 studies in which the majority of the subjects were between 0 and 12 years of age. A classification system is proposed that helped grouping the models, and the interrelationship between this classification and the characteristics of the reviewed studies is explored. The classification could function as an introductory guide and help to select appropriate theories and models when defining future research agenda's. The results of this review may attribute to the refinement of the theoretical underpinning of child education and counseling in physical health.

Knowledge, interests and educational needs of adults diagnosed with Cystic Fibrosis after age 18

BACKGROUND

Little is known about the knowledge, interests, or educational needs of those diagnosed with cystic fibrosis (CF) as adults or the extent to which they find available information helpful. The purpose of this inquiry was to address these gaps.

METHODS

A mailed survey, completed by an international sample (N=130) recruited through internet sites and CF Centers, collected quantitative and qualitative data to address five research questions. A response rate of 74.3% was achieved.

RESULTS

Most participants (67.4%) said they knew little or nothing about CF at diagnosis. Of the 71.5% who indicated they received patient education, 26.9% felt they were given 'too little'. At diagnosis, most wanted disease-related information about CF. Over time they expressed interest in topics related to quality-of-life, such as CF research efforts, alternative medicine and employment issues. Three-fourths (75.4%) were active information seekers, but 60.2% were less than satisfied with what they found. Qualitative responses indicated participants did not 'see themselves' in available materials, which many described as 'depressing'.

CONCLUSIONS

Medical caregivers must be aware of and respond to the unique educational interests and needs of their adult-diagnosed patients. Additional research is recommended to better understand how patient education benefits these adults.

Putting cancer pain management regimens into practice at home

The purpose of this study was to describe the difficulties with pain management that patients and family caregivers bring to a nurse's attention during a teaching and coaching intervention. Data were obtained from audiotaped and transcribed interactions between intervention nurses and patients (n = 52) and their family caregivers (n = 33) who were participating in a randomized clinical trial of a nursing intervention called the PRO-SELF Copyright Pain Control Program. Using qualitative content analysis, we found that patients had difficulty in seven areas when they attempted to put a pain management regimen into practice, namely: obtaining the prescribed medication(s), accessing information, tailoring prescribed regimens to meet individual needs, managing side effects, cognitively processing information, managing new or unusual pain, and managing multiple symptoms simultaneously. The findings from this study suggest that the provision of information about cancer pain management to patients and their family caregivers is not sufficient to improve pain control in the home care setting. Patients and their family caregivers require ongoing assistance with problem-solving to optimize their pain management regimen.

Determinants of adherence in adults with cystic fibrosis

Cystic fibrosis (CF) is now as much a disease of adults as of children and adolescents. An important focus of recent research has been the impact of the complex, expensive, and time consuming routine of self-care and medical treatment that is required by adults with CF to maintain health. A growing concern for medical and allied health teams is the issue of patient adherence to prescribed health management plans. A summary of the particular medical and treatment context of CF is followed by a review of adherence measurement issues and the determinants of adherence to treatment regimens in people with CF, primarily adults. Evidence for factors which influence adherence decisions of people with CF is examined. The medical and psychological aspects of this complex problem have not been adequately addressed because of difficulties with definition and measurement. Only a small proportion of the variance in adherence has been accounted for in the literature. New measurement technologies and new theoretical directions offer promise for a better understanding of this complex and important issue and may result in more effective intervention strategies to improve adherence.

Theoretical development of nursing interventions for sudden cardiac arrest survivors using social cognitive theory

This article discusses the theoretical development of a nursing intervention program to enhance recovery over the first year following sudden cardiac arrest. Concepts from social cognitive theory and domains of concern following sudden cardiac arrest underpin a tailored and standardized nursing intervention. The nursing intervention program is designed for delivery by means of telephone and through the mail. Testing of the nursing intervention program is underway using a clinical trial design.

Development and evaluation of a multi-family psychoeducational program for cystic fibrosis

The development, implementation and evaluation of a psychoeducational program for families with a child affected by cystic fibrosis (CF) is described. Aim of the program was to strengthen the families' coping with CF-related problems and to improve adherence with chest physiotherapy. Sixteen families from an outpatient CF-clinic participated. Parents and children were educated both individually as well as together in multi-family groups. Teaching, practicing and group discussions were balanced in each session. In a pre-post-design the following variables were evaluated: parental coping, parental health beliefs, children's coping, adherence, and knowledge about CF. The parental coping patterns and health beliefs remained unchanged in the study group. Children developed more search for social support, whereas their competence and optimism decreased and withdrawal increased slightly as perceived by the parents. There is a subgroup with poor family functioning and adherence at pretest which improves after the intervention.Family-centered psychoeducational intervention may be a promising supportive strategy for children with CF, especially if it is dedicated to families with poor adaptation to the disease.

Family caregiving skill: development of the concept

Families increasingly are expected to provide complex care at home to ill relatives. Such care requires a level of caregiving knowledge and skill unprecedented among lay persons, yet family caregiving skill has never been formally developed as a concept in nursing. The purpose of the study reported here was to develop the concept of family caregiving skill systematically through qualitative analysis of interviews with patients (n = 30) receiving chemotherapy for cancer and their primary family caregivers (n = 29). Open coding and constant comparison constituted the analytic methods. Sixty-three indicators of caregiving skill were identified for nine core caregiving processes. Family caregiving skill was defined as the ability to engage effectively and smoothly in these nine processes. Properties of family caregiving skill also were identified. Conceptualizing skill as a variable and identifying indicators of varying levels of skill provides a basis for measurement and will allow clinicians to more precisely assess family caregiving skill.

Intervention mapping: a process for developing theory- and evidence-based health education programs

The practice of health education involves three major program-planning activities: needs assessment, program development, and evaluation. Over the past 20 years, significant enhancements have been made to the conceptual base and practice of health education. Models that outline explicit procedures and detailed conceptualization of community assessment and evaluation have been developed. Other advancements include the application of theory to health education and promotion program development and implementation. However, there remains a need for more explicit specification of the processes by which one uses theory and empirical findings to develop interventions. This article presents the origins, purpose, and description of Intervention Mapping, a framework for health education intervention development. Intervention Mapping is composed of five steps: (1) creating a matrix of proximal program objectives, (2) selecting theory-based intervention methods and practical strategies, (3) designing and organizing a program, (4) specifying adoption and implementation plans, and (5) generating program evaluation plans.

Self-management of cystic fibrosis: short-term outcomes of the Cystic Fibrosis Family Education Program

This study tested the efficacy of the Cystic Fibrosis Family Education Program, a cystic fibrosis self-management program, on improving participants' knowledge, self-efficacy, self-management behavior, health, and quality of life. A quasi-experimental pretest-posttest nonequivalent comparison group design was employed. Participants made up 104 patient-primary caregiver dyads from the intervention site cystic fibrosis center and 95 from the usual care comparison center. The intervention, a self-paced print curriculum based on social cognitive theory, targeted behavioral capability, self-efficacy, and outcome expectations and was implemented as an integral part of medical care. Parents, early childhood, middle childhood, and adolescents received separate materials on respiratory, nutrition and malabsorption, communication, and coping issues. Significant intervention effects were found on the knowledge scores for caregivers, adolescents, and children; caregiver and adolescent total self-management scores; Child Behavior Checklist total score; one parent coping scale score; the modified NIH score; NIH pulmonary factor 1; and the Brasfield total score. Significant interaction effects were evident in the self-efficacy scores for caregivers and children.