Parents and partners: lay carers' perceptions of their role in the treatment and care of adults with cystic fibrosis

Development and validation of a short form psychometric tool assessing the caregiving Challenge of Living with Cystic Fibrosis (CLCF-SF) in a child

OBJECTIVE

Caring for a child with cystic fibrosis (CF) is a rigorous daily commitment for caregivers and treatment burden is a major concern. We aimed to develop and validate a short form version of a 46-item tool assessing the Challenge of Living with Cystic Fibrosis (CLCF) for clinical or research use.

DESIGN

A novel genetic algorithm based on 'evolving' a subset of items from a pre-specified set of criteria, was applied to optimise the tool, using data from 135 families.

MAIN OUTCOME MEASURES

Internal reliability and validity were assessed; the latter compared scores to validated tests of parental well-being, markers of treatment burden, and disease severity.

RESULTS

The 15-item CLCF-SF demonstrated very good internal consistency [Cronbach's alpha 0.82 (95%CI 0.78-0.87)]. Scores for convergent validity correlated with the Beck Depression Inventory (Rho = 0.48), State Trait Anxiety Inventory (STAI-State, Rho = 0.41; STAI-Trait, Rho = 0.43), Cystic Fibrosis Questionnaire-Revised, lung function (Rho = -0.37), caregiver treatment management (r = 0.48) and child treatment management (r = 0.45), and discriminated between unwell and well children with CF (Mean Difference 5.5, 95%CI 2.5-8.5, p < 0.001), and recent or no hospital admission (MD 3.6, 95%CI 0.25-6.95, p = 0.039).

CONCLUSION

The CLCF-SF provides a robust 15-item tool for assessing the challenge of living with a child with CF.

Transition from paediatric to adult healthcare for young people with cystic fibrosis: Parents' information needs

Parents of young people with cystic fibrosis (YPWCF) play an important role during the transition from paediatric to adult health services. There is limited evidence on parental information needs and the extent to which they are met. An online survey was conducted targeting a finite population of 190 parents of YPWCF in Ireland. Fifty-nine parents responded (31% response rate). Parents reported the need for more general preparation and timing of the transfer, more information regarding the differences between adult and child health services and how their child will self-manage his/her illness in the future. Most parents received information on the timing of transfer and new healthcare providers but reported being insufficiently informed about their legal status relating to medical confidentiality for their adult child and community resources available for their child after transition to adult health services. The findings highlight the importance of information and preparation for caregivers as well as young people to promote successful transition to adult healthcare. Providing parents with clear information and anticipatory guidance are simple changes in practice that may lead to improvements in transition experiences.

Parenting a child with chronic illness as they transition into adulthood: A systematic review and thematic synthesis of parents' experiences

OBJECTIVE

To understand how parents view and experience their role as their child with a long-term physical health condition transitions to adulthood and adult healthcare services.

METHODS

Five databases were systematically searched for qualitative articles examining parents' views and experiences of their child's healthcare transition. Papers were quality assessed and thematically synthesised.

RESULTS

Thirty-two papers from six countries, spanning a 17-year period were included. Long-term conditions were diverse. Findings indicated that parents view their child's progression toward self-care as an incremental process which they seek to facilitate through up-skilling them in self-management practices. Parental perceptions of their child's readiness, wellness, competence and long-term condition impacted on the child' progression to healthcare autonomy. A lack of transitional healthcare and differences between paediatric and adult services served as barriers to effective transition. Parents were required to adjust their role, responsibilities and behaviour to support their child's growing independence.

CONCLUSION

Parents can be key facilitators of their child's healthcare transition, supporting them to become experts in their own condition and care. To do so, they require clarification on their role and support from service providers.

PRACTICE IMPLICATIONS

Interventions are needed which address the transitional care needs of parents as well as young people.

Flying the nest: a challenge for young adults with cystic fibrosis and their parents

OBJECTIVES

As young patients with cystic fibrosis (CF) grow up, they are expected to take increasing responsibility for the treatment and care of their disease. The aim of this study was to explore the disease-related challenges faced by young adults with CF and their parents, when they leave home.

MATERIALS AND METHODS

A questionnaire survey of Danish patients with CF aged 18-25 years and their parents was conducted. The questionnaires were based on focus-group interviews with young adults with CF and their parents, and addressed challenges faced in the transition phase between childhood and adulthood, including different areas of disease management in everyday life.

RESULTS

Among all of the patients invited, 62% (n=58/94) of young adults and 53% (n=99/188) of their parents participated in the study. In total, 40% of the 18- to 25-year-olds were living with their parents, and the parents continued to play an active role in the daily care of their offspring's disease. Among the young adults who had left home, both the patients and their parents reported many difficulties regarding disease management; the young adults reported difficulties in contacting social services and in affording and preparing sufficient CF-focused meals, and their parents reported difficulties in answering questions concerning social rights and CF in general, and in knowing how to give their offspring the best help, how much to interfere, and how to relinquish control of managing their offspring's disease.

CONCLUSION

Young adults with CF who have left home have difficulties in handling the disease and their parents have difficulties in knowing how to give them the best help. There is an urgent need for holistic CF transitional care, including ensuring that young adults master the essential skills for self-management as they leave their parents.

Perception of first respiratory infection with Pseudomonas aeruginosa by people with cystic fibrosis and those close to them: an online qualitative study

BACKGROUND

People with cystic fibrosis (CF) are susceptible to respiratory infection with Pseudomonas aeruginosa (PA), which may become chronic if initial eradication fails. Environmental acquisition and person-to-person transmission can occur. Respiratory PA infection is associated with increased mortality and more hospitalisations. This may cause patients and families anxiety and lead them to adopt preventive measures which may be ineffectual and intrusive. It is not possible to hold a conventional focus group to explore these issues because people with CF cannot meet together due to the risk of cross-infection.

OBJECTIVE

To explore the perceptions of first respiratory infection with PA in people with CF and those close to them.

DESIGN

We designed an online survey, to maximise accessibility and avoid the risk of cross-infection. This established the respondent's relationship with CF, asked 3 open questions about perceptions of PA and a final question about the prioritisation of research. Responses were analysed using a structured, iterative process. We identified keywords, analysed these incontext and derived key themes.

SETTING

Promotion through social media allowed respondents from any country to participate.

PARTICIPANTS

People with CF and those close to them.

RESULTS

Responses were received from 393 people, including 266 parents and 97 people with CF. The key themes were the emotional burden of PA (fear in particular); the burden of treatment PA entails and the need for accurate knowledge about PA.

CONCLUSIONS

Lack of knowledge and the health beliefs of individuals may promote fear of infection and inappropriate avoidance measures. Uncertainty about the implications of PA infection and the treatment required may cause anxiety. Healthcare professionals should provide clear information about how PA might be acquired and the treatment necessary, making clear the limitations of current understanding and acknowledging health beliefs.

"We Sometimes Hold on to Ours" - Professionals' Views on Factors that both Delay and Facilitate Transition to Adult Care

BACKGROUND

The transition from child to adult services is a crucial time in the health of young people who may potentially fall into a poorly managed "care gap." Health service provision, which fails to meet the needs of young people and families at this time of significant change, may result in deterioration in health or disengagement with services, which can have negative long-term consequences. Developing transitional care packages has become a focus of activity in the United Kingdom and elsewhere. Indeed, policy documents have been trying to guide practice for many years, with some variable success. There is much work still to be done, particularly around how guidance and the sharing of best practice, when combined can result in a change in practice.

OBJECTIVE

This study aimed to explore the views of professionals involved in transitional care, the process of transition in their services, and the barriers and facilitators to transition.

METHODS

This was a qualitative study using focus group methodology. Four focus groups were carried out, attended by 36 health professionals across child and adult services. They had expertise in working with young people with various health conditions and disabilities. Transcripts were analyzed using qualitative content analysis.

RESULTS

Eight key factors that impact on transition emerged from the data. These included factors associated with the patient group (such as age, health condition, having complex needs) as well as factors associated with services (such as the availability of equivalent services within adult care and the links between child and adult team).

CONCLUSION

It is imperative that health professionals consider the population they are working with when planning transitional care and take into account the factors which can lead to delayed transition, so that this can be avoided if possible. Numerous examples of initiatives to facilitate more timely transition were shared: these have been reflected in our "Benchmarks for Transition from Child to Adult Health Services." We offer these benchmarks to inform and guide the practice of others and illustrate their potential for use in the context of the findings shared here.

Adults with cystic fibrosis - responding to a new ageing population

Worldwide, the life expectancy of adults with cystic fibrosis has increased substantially over the last two decades and cystic fibrosis can no longer be regarded as a paediatric condition. Adults with cystic fibrosis are becoming a new ageing population and are working, having families of their own and are likely to retire due to old age rather than ill health. Despite this progress, little is known about how people with cystic fibrosis are experiencing ageing with this long-term condition and how prepared they are for older age. This paper highlights the implications that ageing with cystic fibrosis may have for specialist health services and in particular the individual with cystic fibrosis, as well as providing pointers for future research.

[The experience of disease in cystic fibrosis: the paths to comprehensive care]

Cystic Fibrosis is a chronic disease with an extensive impact on family life. The experience of disease is the manner how individuals respond to the disease, assigning meaning meanings and searching for ways to deal with it in their daily lives. The objective of this study was to understand the experience of Cystic Fibrosis in the family context. This is an ethnographic study, performed with families of children assisted at a teaching hospital located in the state of São Paulo. Results were divided into the themes past, present and future, and all phases were permeated with the search for the meaning of the disease and social support, the importance of religion and spirituality, and child's socialization. Knowing the experience in the disease and the social network is indispensible when planning comprehensive care. This is an innovative approach in health care for chronic diseases.

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.

What is the perceived nature of parental care and support for young people with cystic fibrosis as they enter adult health services?

The majority of those diagnosed with cystic fibrosis (CF) now live to adulthood. In response to increased survival age, transition services have been developed to ensure smooth transfer from paediatric to adult specialist healthcare, although the majority of treatment and care continues to be delivered in the home. However, little is known about how young adults and staff conceptualise the nature of the parental role after young people have left paediatric care. The aim of this study is to explore the nature of parental support that is perceived to be available at this time. As part of a larger study of transitional care, semi-structured interviews were conducted with 50 young people with CF aged 13-24 years (32 with experience of transition and/or adult CF services) and 23 specialist healthcare professionals (14 working in adult care) across two CF centres in Southeast England. Interviews took place in young people's homes or within CF services, using a topic guide and were recorded, transcribed and analysed thematically. Four domains of perceived parental support were identified by the young people interviewed, with varying degrees of continuity into adult care: (1) Providing non-clinical practical and emotional support; (2) Acting as 'troubleshooters' in times of health-related crisis; (3) Working in partnership with offspring in ongoing disease management in the home and clinic; (4) Acting as 'protectors' of their children. Young people and service staff expressed tensions in managing parental involvement in post-paediatric consultations and the degree to which parents should be aware of their offspring's deteriorating health and social concerns. Parental anxiety and over-involvement was perceived by many young people and staff as unsupportive. We suggest that although health and social care providers are mindful of the tensions that arise for those leaving paediatric services, the place of parental support in adult care is currently contentious for these 'new' ageing populations.

Self-reported involvement of family members in the care of adults with CF

BACKGROUND

Few empirical studies have examined the role of family caregivers in the lives of adults with CF.

METHODS

As part of the Project on Adult Care in CF (PAC-CF), an on-going prospective, longitudinal panel study of adults with CF, 119 family members and friends of adults with CF completed a mail survey in which they reported the frequency of help they provide for their family member with CF during routine care, hospitalization, and home IV treatment.

RESULTS

The 119 caregivers were mainly spouses or unmarried partners (56%) and parents (29%). Fifteen percent of caregivers were children, friends, siblings or roommates. Family caregivers for adults with CF report assisting mainly with communication and social support during routine treatment, although one third provide some clinical care on a regular basis. Family caregivers report an increase in assistance during periods of acute illness, such as during a hospitalization and home IV treatment, especially with clinical care tasks.

CONCLUSIONS

The depth of commitment required of families of children with CF has been well documented for decades. Our results suggest that the responsibilities of family members diminish only moderately as those with CF reach adulthood.

From child to adult: An exploration of shifting family roles and responsibilities in managing physiotherapy for cystic fibrosis

Although chest physiotherapy is central to the management of cystic fibrosis many report problems with adherence. Research in other long-term conditions suggests that non-adherence may be exacerbated as the child grows older and self-care responsibilities are transferred to the young person. We explored the nature and variation in roles of family members, how responsibility was transferred from the parent/family to the child, and what factors aided or hindered this process. We conducted in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7-17 years, and with 31 parents attending cystic fibrosis clinics in two Scottish regions. Family responsibilities were primarily focused on mothers. The level and nature of involvement varied along a continuum that separated into six parental and five child roles and changed over time. However, this movement was frequently reversed during periods of illness or mistrust. The day to day experience of such a transfer was not straightforward, linear or unproblematic for any of the family members. Three factors were identified as assisting the transfer of responsibility: parents' perceptions of the benefits of transferring responsibility, children's perceptions of the benefits, and the available physical, social and psychological resources to support such a transfer. The principles and lessons from "concordance" (a therapeutic alliance based on a negotiation between equals and which may lead to agreement on management or agreement to differ) may provide a foundation for newly developing relationships between parents and their children emerging into adulthood. Further research is required to develop more specifically the content and structure of required support, its effectiveness in achieving more concordant relationships, and the resulting impact on adherence, perceived health and well-being from the perspective of the young person and parent.

The health of chronically ill children: lessons learned from assessing family caregiver quality of life

This study aims to assess family caregiver quality of life (QOL) and its relationship to the health of chronically ill children. Family caregivers (n = 100) completed the Medical Outcomes Short Form 36, Beck Depression Inventory, and Caregiver Quality of Life for Cystic Fibrosis Scale. Disease severity data were collected for children with cystic fibrosis. Analysis revealed significant QOL issues; and as the child's disease severity increases, the QOL of the caregiver decreases. A relationship exists between the child's and caregiver's health. Program recommendations to benefit family caregiver health and in turn benefit health of chronically ill children are discussed.