The Influence of Parental Supervision on Medical Adherence in Adolescents With Cystic Fibrosis: Developmental Shifts From Pre to Late Adolescence

The application of the self-care deficit nursing theory in adolescents with cystic fibrosis: A randomized controlled study

PURPOSE

The present study evaluates the effects of the application of Self-Care Deficit Nursing Theory (SCDNT) on the self-care knowledge and skills in adolescents with Cystic Fibrosis.

DESIGN AND METHODS

This randomized controlled study included 30 adolescents who were equally divided into the intervention and control groups. The data were collected by using the Sociodemographic Data Form and the Self-Care Knowledge and Skills Evaluation Forms for Adolescents with Cystic Fibrosis. A total of seven home visits were conducted with the adolescents in the intervention group, during which individualized care plans were applied based on the Self-Care Deficit Nursing Theory. The self-care needs of the adolescents in the control group were identified based on data collected during two home visits conducted at the onset of the study and after 4.5 months.

RESULTS

As a result of the application of nursing interventions based on the SCDNT, a statistically significant increase was noted in the self-care knowledge and skills of the adolescents in the intervention group (p < 0.05). Additionally, after the interventions based on SCDNT, the need of adolescents for nursing interventions decreased significantly over time in all adolescents in the intervention group (p < 0.05).

CONCLUSIONS

The application of nursing interventions based on the SCDNT was effective in enhancing the self-care knowledge and skills of adolescents with Cystic Fibrosis.

PRACTICE IMPLICATIONS

Nurses can benefit from Orem's Self-Care Deficit Nursing Theory in the design and application of the individualized care of adolescents with Cystic Fibrosis to improve their self-care practices.

Modification of an Intervention to Improve Adherence in Adolescents and Young Adults With Bipolar Disorder

Objective

Managing bipolar disorder (BD) is particularly challenging for adolescents and young adults (AYAs) ages 16 to 21. Few interventions exist that address self-management in AYAs with BD. Thus, this study aimed to modify the customized adherence enhancement behavioral intervention for AYAs through an iterative, patient-centered process.

Method

The Obesity-Related Behavioral Intervention Trials (ORBIT) model was used for intervention development. In phase 1a, adherence barriers and facilitators were identified to refine intervention content. Phase 1b occurred following curriculum modification to ensure that the modified intervention was relevant and usable by the target population. Data were collected via focus groups and interviews with AYAs with BD, parents, and providers. Transcripts were analyzed using directed content analysis.

Results

Phase 1a included focus groups/interviews with AYAs (n = 10), parents (n = 4), and providers (n = 9) who described the difficulties and successes in managing BD symptoms, improving adherence, and transitioning care from caregivers. Phase 1b included an advisory board composed of 8 phase 1a participants who provided feedback on modified session activities, module delivery, and curriculum. Phase 1b involved usability testing with new participants (n = 8), revealing the need for modifiable language based on developmental level, more engaging visual images, and confirmation that topics were salient to AYAs with BD.

Conclusion

Though sample sizes were small and not representative of the population of AYAs with BD, the ORBIT methodology informed the adaptation of the customized adherence enhancement intervention to improve adherence in AYAs with BD. Important next steps are to conduct a pilot randomized clinical trial of customized adherence enhancement for AYAs.

Pilot randomized controlled clinical trial of an adherence social norms intervention for adolescents with epilepsy

OBJECTIVE

Non-adherence to anti-seizure medications (ASMs) is common for adolescents with epilepsy, with potentially devastating consequences. Existing adherence interventions in epilepsy do not meet the unique challenges faced by adolescents. Leveraging social norms capitalizes on the increased importance of peer influence while simultaneously targeting the low motivation levels of many adolescents. The current study examined the feasibility, acceptability, and satisfaction of a social norms adherence intervention in adolescents with epilepsy.

METHODS

A pilot RCT of a mHealth social norms intervention was conducted with adolescents with epilepsy who demonstrated non-adherence (≤95% adherence) during baseline. Adolescents were randomized to either (1) mHealth social norms (reminders, individualized and social norms adherence feedback) or (2) control (reminders and individualized adherence feedback). Primary outcomes included feasibility, acceptability, and satisfaction. Exploratory outcomes included electronically monitored adherence, seizure severity, and health-related quality of life (HRQOL).

RESULTS

One hundred four adolescents were recruited (53% female; Mage = 15.4 ± 1.4 years; 81% White: Non-Hispanic; 5% Black, 10% Bi/Multiracial; 2% White: Hispanic; 1% Other: Hispanic; 1% Bi/Multiracial-Hispanic). Forty-five percent screen-failed due to high adherence, 16% withdrew, and 38% were randomized to treatment (n = 19) or control (n = 21). Recruitment (75%), retention (78%), and treatment satisfaction were moderately high. Engagement with the intervention was moderate, with 64% of participants engaging with intervention notifications. Exploratory analyses revealed that after controlling for COVID-19 impact, the social norms intervention group maintained higher adherence over time compared to the control group. Small to moderate effect sizes were noted for seizure severity and HRQOL between groups.

CONCLUSION

This pilot intervention appeared feasible and acceptable. Increases in adherence in the treatment versus control group were modest, but a future larger more adequately powered study is needed to detect effects. Notably, it appeared the COVID pandemic influenced adherence behaviors during our trial.

Digital technology for monitoring adherence to inhaled therapies in people with cystic fibrosis

BACKGROUND

Improved understanding and treatment of cystic fibrosis (CF) has led to longer life expectancy, which is accompanied by an increasingly complex regimen of treatments. Suboptimal adherence to the treatment plan, in the context of respiratory disease, has been found to be associated with poorer health outcomes. With digital technology being more accessible, it can be used to monitor adherence to inhaled therapies via chipped nebulisers, mobile phone apps and web-based platforms. This technology can allow monitoring of adherence as well as clinical outcomes, and allow feedback to both the person with CF and their healthcare team.

OBJECTIVES

To assess the effects of using digital technology to monitor adherence to inhaled therapies and health status in adults and children with CF.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books.  Date of last search: 28 October 2021. We also searched Embase and three clinical trial registries and checked references of included studies. Date of last search: 9 November 2021.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) looking at the effects of a digital technology for monitoring adherence of children and adults with CF to inhaled therapies.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search results for studies eligible for inclusion in the review and extracted their data. We used Risk of Bias 2 for assessing study quality. We assessed the overall certainty of the evidence using GRADE.

MAIN RESULTS

We included two studies in our review, with 628 participants aged five to 41 years. There was one study each for two different comparisons.  Nebuliser target inhalation mode versus standard inhalation mode The included parallel study was carried out over 10 weeks after a run-in period of four to six weeks. The study compared the effects of a digitally enhanced inhalation mode (target inhalation mode) for nebulised antibiotics compared to standard mode in children attending a regional CF clinic in the United Kingdom. The study's primary outcome was the time taken to complete the inhaled treatment, but investigators also reported on adherence to therapy. The results showed that there may be an improvement in adherence with the target inhalation mode when this intervention is used (mean difference (MD) 24.0%, 95% confidence interval (CI) 2.95 to 45.05; low-certainty evidence). The target inhalation mode may make little or no difference to forced expiratory volume in one second (FEV1) % predicted (MD 1.00 % predicted, 95% CI -9.37 to 11.37; low-certainty evidence). The study did not report on treatment burden, quality of life (QoL) or pulmonary exacerbations. eNebuliser with digital support versus eNebuliser without support One large multicentre RCT monitored adherence via data-tracking nebulisers. The intervention group also receiving access to an online web-based platform, CFHealthHub, which offered tailored, flexible support from the study interventionist as well as access to their adherence data, educational and problem-solving information throughout the 12-month trial period. We graded all evidence as moderate certainty. Compared to usual care, the digital intervention probably improves adherence to inhaled therapy (MD 18%, 95% CI 12.90 to 23.10); probably leads to slightly reduced treatment burden (MD 5.1, 95% CI 1.79 to 8.41); and may lead to slightly improved FEV1 % predicted (MD 3.70, 95% CI -0.23 to 7.63). There is probably little or no difference in the incidence of pulmonary exacerbations or QoL between the two groups.

AUTHORS' CONCLUSIONS

Digital monitoring plus tailored support via an online platform probably improves adherence to inhaled therapies and reduces treatment burden (but without a corresponding change in QoL) in the medium term (low- and moderate-certainty evidence). In a shorter time frame, technological enhancement of inhaling antibiotics may improve adherence to treatment (low-certainty evidence). There may be little or no effect on lung function with either intervention, and online monitoring probably makes no difference to pulmonary exacerbations.  Future research should assess the effect of digital technology on adherence in both children and adults. Consideration of adherence to the total treatment regimen is also important, as an improvement in adherence to inhaled therapies could come at the cost of adherence to other parts of the treatment regimen.

AIM2ACT: Randomized controlled trial protocol for a mobile health intervention for early adolescents with asthma

Early adolescents diagnosed with asthma have difficulties consistently performing disease self-management behaviors, placing them at-risk for poor asthma control, morbidity, and reduced quality of life. Helpful caregiver support is pivotal in determining whether early adolescents develop and master asthma self-management behaviors. We developed Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT), a mobile health intervention to facilitate helpful caregiver support in early adolescents (12-15 year-olds) with poorly controlled asthma. AIM2ACT is a dyadic smartphone intervention that contains three components: 1) ecological momentary assessment to identify personalized strengths and weaknesses in asthma self-management behaviors; 2) collaborative identification and tracking of goals that help early adolescents to become increasingly independent in managing their asthma; and 3) a suite of skills training videos. This paper describes our plans to test the efficacy of AIM2ACT and evaluate long-term maintenance of treatment effects in a fully powered randomized controlled trial with 160 early adolescents with poorly controlled persistent asthma, ages 12-15 years, and a caregiver. Families will be randomly assigned to receive AIM2ACT (n = 80) or a mHealth attention control condition (n = 80) that accounts for attention and novelty of a technology-based intervention for 6 months. Assessments will occur at baseline, post-intervention, and 3-, 6-, and 12-month follow-up time points. We will collect patient-reported and objectively monitored (e.g., spirometry, adherence) outcomes. Given the timing of the trial, a secondary exploratory goal is to evaluate the perceived impact of COVID-19 on family functioning and parental control of their adolescent's asthma in the context of our intervention.

A customized adherence enhancement program for adolescents and young adults with suboptimal adherence and bipolar disorder: Trial design and methodological report

BACKGROUND

The onset of bipolar disorder (BD) is common during late adolescence and young adulthood (AYA). Suboptimal medication adherence is a critical yet modifiable risk factor for negative outcomes among AYAs with BD.

METHODS

This research used an iterative process (e.g., focus groups, advisory board, cognitive interviews) to modify an existing adherence intervention to address suboptimal adherence in AYAs with BD. The modified version of Customized Adherence Enhancement for Adolescents and Young Adults (CAE-AYA) will be compared to an Enhanced Treatment as Usual condition (ETAU) in 40 AYAs intervention using a 6-month prospective, randomized controlled trial (RCT) in a high-risk group of 16-21 year old AYAs with BD with demonstrated non-adherence to their prescribed BD medications.

CONCLUSIONS

This report describes the methodology and design of the ImprovinG adhereNce In adolescenTs with bipolar disordEr (IGNITE) study. If successful, the CAE-AYA approach has the potential to advance care for vulnerable youth with BD.

Characteristics and management of adolescents attending the ED with fever: a prospective multicentre study

OBJECTIVE

Most studies on febrile children have focused on infants and young children with serious bacterial infection (SBI). Although population studies have described an increased risk of sepsis in adolescents, little is known about febrile adolescents attending the emergency department (ED). We aimed to describe patient characteristics and management of febrile adolescents attending the ED.

DESIGN AND SETTING

The MOFICHE/PERFORM study (Management and Outcome of Febrile Children in Europe/Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union), a prospective multicentre study, took place at 12 European EDs. Descriptive and multivariable regression analyses were performed, comparing febrile adolescents (12-18 years) with younger children in terms of patient characteristics, markers of disease severity (vital signs, clinical alarming signs), management (diagnostic tests, therapy, admission) and diagnosis (focus, viral/bacterial infection).

RESULTS

37 420 encounters were included, of which 2577 (6.9%) were adolescents. Adolescents were more often triaged as highly urgent (38.9% vs 34.5%) and described as ill appearing (23.1% vs 15.6%) than younger children. Increased work of breathing and a non-blanching rash were present less often in adolescents, while neurological signs were present more often (1% vs 0%). C reactive protein tests were performed more frequently in adolescents and were more often abnormal (adjusted OR (aOR) 1.7, 95% CI 1.5 to 1.9). Adolescents were more often diagnosed with SBI (OR 1.8, 95% CI 1.6 to 2.0) and sepsis/meningitis (OR 2.3, 95% CI 1.1 to 5.0) and were more frequently admitted (aOR 1.3, 95% CI 1.2 to 1.4) and treated with intravenous antibiotics (aOR 1.7, 95% CI 1.5 to 2.0).

CONCLUSIONS

Although younger children presented to the ED more frequently, adolescents were more often diagnosed with SBI and sepsis/meningitis. Our data emphasise the importance of awareness of severe infections in adolescents.

Cystic fibrosis-related diabetes: The patient perspective

Cystic fibrosis-related diabetes (CFRD) affects nearly 20% of adolescents and 40-50% of adults. However, the impact on patients and their families is poorly understood. Here, we examine how patients perceive CFRD and identify gaps in our understanding of the patient experience. Despite its relatively high prevalence, data suggest that many individuals are not aware of the possibility of developing CFRD or compare it to other types of diabetes. Annual oral glucose tolerance testing (OGTT) may serve as an opportunity to provide education and prepare individuals for the possibility of developing abnormalities in glucose tolerance. Many cite lack of awareness of CFRD as the most difficult part of the diagnosis. While factors such as older age and a strong support system promote acceptance, most individuals view the diagnosis negatively and struggle to balance the demands of diabetes with other obligations, including airway clearance, nebulizer therapies, supplementation nutrition, and administration of vitamins and medications. Relatively few people with CFRD monitor their blood glucoses consistently, which is attributed to time constraints or an attempt to avoid pain. In addition, many feel that they are not prone to hypoglycemia and are not concerned with long-term complications, anticipating that they will succumb to their pulmonary disease before these become problematic. The adolescent period presents unique challenges for adherence as children work to develop autonomy. Factors that promote CFRD adherence include incorporating management into daily CF routines and the support of knowledgeable providers to help develop an individualized approach to management. Diabetes technology has the potential to reduce treatment burden and improve glycemic control, but data in CFRD are limited, and additional study is needed. Given that CFRD is associated with a decline in health-related quality of life, it is critical that providers understand patients' perspectives and address gaps in understanding and barriers to management.

Emerging Adults' Adherence to Preventative Health Guidelines in Response to COVID-19

Objective

To examine rates of emerging adults’ (EA) adherence to preventative health behavior recommendations during early months of the COVID-19 pandemic and to investigate demographic (i.e., gender, years of education, socioeconomic status, school enrollment status, and living situation) and exposure and impact-related correlates of adherence.

Methods

Participants were 273 [M (SD) age = 22 (2.1) years, 55% female, 32% from minoritized groups] EA completed an online survey of adherence to 11 preventative health behaviors recommended by the Centers for Disease Control (CDC) during summer 2020. Participants rated adherence via a visual analog scale. Participants also reported demographic information and completed the COVID-19 Exposure and Family Impact Adolescent and Young Adult Version (CEFIS-AYA).

Results

Median levels of adherence to preventative recommendations ranged from 66% to 100%. Highest adherence levels (Mdn > 90%) were reported for quarantining if exposed to COVID-19; covering mouth when sneezing; avoiding the elderly/those at high risk; and avoiding large gatherings. Median adherence was <80% for mask wearing; maintaining a 6-foot distance; avoiding in-person visits with romantic partners or friends; and disinfecting surfaces. Female gender was the only variable significantly associated with overall adherence, and it explained 4% of the variance.

Conclusions

Following guidelines related to social distancing practices may be particularly challenging for EA, possibly because of unique developmental needs of this group, and males may be at greater risk for non-adherence to CDC recommendations. Therefore, public health messaging and adherence intervention development should be designed with males and social distancing practices in mind.

Psychometric evaluation of the brief RCOPE and relationships with psychological functioning among caregivers of children undergoing hematopoietic stem cell transplant

OBJECTIVE

Spiritual and religious (S/R) coping is a relevant yet understudied domain of coping among caregivers of children undergoing hematopoietic stem cell transplantation (HCT). The aims of this manuscript are to: (1) conduct the first psychometric evaluation of the Brief RCOPE in this population; (2) examine levels of and changes in S/R coping over time; and (3) explore the relationship between S/R coping trajectories and psychological functioning post-HCT.

METHODS

Caregivers (n = 170) of children (ages ≤12 years, n = 170) undergoing HCT completed the Brief RCOPE and the Brief Symptom Inventory (BSI) pre- and at multiple time points post-HCT discharge. Factor structure, internal consistency, and validity were examined. Growth mixture models were used to identify subgroups with similar S/R coping trajectories, with group memberships added to mixture models to explore relationships between group membership and caregiver psychological functioning trajectories.

RESULTS

The Brief RCOPE exhibited the previously-supported two factor structure and each subscale demonstrated strong internal consistency (α = 0.85 and 0.92). Validity was supported by significant correlations with BSI scores. There were distinct subgroups of caregivers with different patterns of positive (n = 4 subgroups) and negative (n = 3 subgroups) S/R coping, with negative coping subgroup membership predicting changes in psychological functioning.

CONCLUSIONS

The Brief RCOPE is a promising measure for assessing S/R coping among caregivers of children undergoing HCT and has the potential to identify caregivers at risk for poorer long-term psychological functioning.

Examining Risk Factors of Health-Related Quality of Life Impairments Among Adolescents with Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a chronic, costly, and burdensome disease that is typically diagnosed during adolescence. Despite the use of effective treatments, rates of relapse and intestinal inflammation remain high and put patients at risk for long term physical and psychosocial health complications. Given the costs associated with IBD, it is critical to examine potential risk factors of poor health-related quality of life (HRQoL) among patients for the enhancement and further development of interventions. As such, the aim of the current study was to examine how sociodemographic and disease characteristics, psychosocial problems, and adherence behaviors impact HRQoL among a sample of youth with IBD. 107 adolescents with IBD and their caregiver completed self- and parent-report measures as part of a psychosocial screening service. Medical records were reviewed to obtain information regarding diagnosis, insurance, medication use, illness severity, and disease activity. Results revealed lower HRQoL scores among adolescents with more psychosocial problems (Est. = -3.08; p < .001), greater disease severity (Est. = -.40; p = .001), and those who identified as Black (Est. = -.38; p < .05). Greater disease severity (Est. = .13 p = .004), use of nonpublic insurance (Est. = .32 p = .004), and fewer psychosocial problems (Est. = -.13 p = .04) were associated with greater adherence behaviors. These findings suggest that implementing individually tailored, evidence-based psychological interventions focused on coping with psychosocial problems and symptoms may be important in enhancing adherence behaviors and HRQoL among adolescents with IBD.

The development of a social norms adherence intervention for adolescents with epilepsy

INTRODUCTION

Adherence is suboptimal in adolescents with epilepsy. Social norms comparison (i.e., feedback about someone else's behavior related to one's own behavior) strategies may be beneficial in improving medication adherence. Using a novel model of behavioral intervention development, the aim of the current study was to create a social norms intervention for adolescents with epilepsy via focus groups and usability studies.

METHODS

A focus group, individual interviews, short-term usability, and extended usage testing studies were conducted. Across all study phases, content and images of intervention components were displayed to participants as mock-ups in PowerPoint slide decks. After each phase, updated iterations were shown to participants to refine the intervention. Several questionnaires were completed by adolescents and caregivers to characterize the samples.

RESULTS

Twelve adolescents participated in the focus group/individual interviews and usability studies. The final Behavioral Economic Adherence for Teens (BEAT) intervention consists of a text messaging system and a graphical user interface. General feedback indicated the need for simplicity and ease of use regarding obtaining the graphical messages (e.g., no extra login and passwords); engaging visual images; and weekly comparisons of a target patient's medication adherence to other adolescents' performance. The average system usability system (SUS) rating was 88.3 + 3.8.

CONCLUSIONS

Our final intervention had high usability ratings and was perceived as engaging and easy to understand. An important next step is to test the BEAT intervention in a Phase 2 randomized trial.

Asthma Management Responsibility, Control, and Quality of Life Among Emerging Adolescents

OBJECTIVE

To examine how asthma control is related to the association between the division of responsibility for asthma management and asthma-related quality of life among early adolescents.

METHODS

Forty-nine youth aged 10-15 years (Mage = 12.25, 57.1% female) with a physician-verified asthma diagnosis completed the Standardized Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and Asthma Control Test (ACT). Youth and their caregivers also completed the Asthma Responsibility Questionnaire (ARQ). Higher ACT scores indicate better asthma control.

RESULTS

There was a significant difference in ARQ scores between youth and caregivers (p < .001, d = .94). Youth reported sharing equal responsibility for asthma management with caregivers, while caregivers reported having more responsibility relative to youth. Greater youth-reported ARQ (p = .004) and greater ACT scores (p < .001) were associated with higher PAQLQ scores. ACT scores moderated the effect of youth-reported ARQ on PAQLQ scores (p = .043). For youth with lower ACT scores, higher youth-reported responsibility was associated with higher PAQLQ scores; while for youth with higher ACT scores, PAQLQ scores were high regardless of perceived responsibility. The interaction between caregiver ARQ scores and ACT scores was not significant.

CONCLUSION

This study suggests youth and caregivers report discrepant ARQ for asthma management tasks. Responsibility and level of asthma control are important factors for PAQLQ, with results indicating that fostering responsibility is an important factor, even among youth with poorly controlled asthma. Findings suggest that healthcare providers should assess family responsibility and help caregivers support adolescents in developing asthma management skills.

Patient, Caregiver, and Provider Perceptions of Transition Readiness and Therapeutic Alliance during Transition from Pediatric to Adult Care in Epilepsy

Transition from pediatric to adult health care is a time of high risk for adolescents and young adults (AYAs) with epilepsy. Our aims are to examine patient, caregiver, and provider perceptions of transition readiness and the influence of patient-provider alliance in the context of transition readiness. Our cross-sectional study included 82 AYAs with epilepsy prior to transition. Patients, caregivers, and providers completed questionnaires (e.g., transition readiness and working alliance). Statistical analyses included independent samples and paired t-tests. Participants were 17.3 ± 2.8 years on average, 54% were females, 84% were White (non-Hispanic), and 38% had generalized epilepsy. Caregivers reported significantly higher transition readiness than their AYAs (t (72) = −10.6, p < 0.001). AYAs and providers reported similar alliance scores. Providers who felt patients were ready to transition had higher patient-reported transition readiness and provider-reported alliance scores. These data suggest that patients and providers are well aligned in the transition process, and providers appropriately perceive key areas necessary for transition. Caregivers and patients had discrepant perceptions of transition readiness, highlighting the importance of assessing both unique transition perspectives. Dedicated transition programs are likely to be beneficial in improving transition readiness and increase alignment across patients, caregivers, and providers.

Concurrent and Longitudinal Associations among Parenting Style, Responsibility, and Adherence in Youth with Cystic Fibrosis

In an effort to identify pathways for improvements in clinical monitoring and intervention, the current study investigated the role that parenting style plays in treatment adherence and responsibility for youth with CF. Participants (n = 50) completed questionnaires related to treatment adherence, treatment responsibility, and parenting style at baseline and at a two year follow up visit. Aspects of parenting style (e.g., warmth, autonomy support) were related to youth adherence and responsibility in cross-sectional and prospective analyses. These data suggest that aspects of parenting may be important targets of interventions to promote treatment adherence in youth with CF.

Introduction to Cystic Fibrosis for Mental Health Care Coordinators and Providers: Collaborating to Promote Wellness

To maximize health, individuals with cystic fibrosis (CF) follow a complex, burdensome daily care regimen. Managing CF is associated with a range of significant biopsychosocial challenges and places individuals with CF, and their caregivers, at greater risk for developing anxiety and depression. To promote wellness and address the potential barriers that affect management of this complex chronic illness, many individuals would benefit from treatment from a behavioral health provider. Social workers within multidisciplinary CF care teams are well positioned to respond to this need, and an expanding number of social workers serving as behavioral health providers in the community will be sought as a resource to provide treatment to this population. This article serves as a primer for social workers to maximize knowledge of the psychosocial and potential behavioral health needs of individuals with CF across the life span. To best support individuals with CF, authors describe the disease-specific manifestations and outline the numerous potential clinical targets for social work to promote wellness. The article concludes by highlighting the importance of communication with the medical team and considerations for effective collaborative care.

Patient Health Beliefs and Characteristics Predict Longitudinal Antihypertensive Medication Adherence in Adolescents With CKD

Objective

To investigate longitudinal associations of health beliefs, which included self-efficacy, outcome expectancies, and perceived barriers, and demographic risk factors (i.e., age, gender, race, and family income) with antihypertensive medication adherence in adolescents with chronic kidney disease (CKD) over 24 months.

Method

The sample included 114 adolescents (M age = 15.03 years, SD = 2.44) diagnosed with CKD. Adolescents reported their self-efficacy for taking medications, medication outcome expectancies, and barriers to adherence at baseline and 12 and 24 months after baseline. Antihypertensive medication adherence was assessed via electronic monitoring for 2 weeks at baseline and 6, 12, 18, and 24 months after baseline.

Results

Adherence increased and then decreased over the 2-year study period (inverted U-shape). Self-efficacy, outcome expectancies, and barriers did not change over time. Older adolescent age, female gender, African American race, <$50,000 annual family income, and public health insurance were associated with lower adherence. However, family income was the primary demographic risk factor that predicted adherence over time (≥$50,000 annual family income was longitudinally associated with higher adherence). Higher self-efficacy and more positive and less negative outcome expectancies across time were also associated with higher antihypertensive medication adherence across time.

Conclusions

Clinical interventions should be developed to target medication self-efficacy and outcome expectancies to improve long-term antihypertensive medication adherence in adolescents with CKD. Family income may be considered when conceptualizing contextual factors that likely contribute to adolescents' consistent challenges with medication adherence over time.

Allocation of Treatment Responsibility in Adolescents With Epilepsy: Associations With Cognitive Skills and Medication Adherence

Objectives

To describe allocation of treatment responsibility (ATR) in adolescents with epilepsy, investigate associations between cognitive skills and ATR, and examine whether ATR for antiepileptic drugs (AEDs) predicted electronically monitored adherence.

Method

Sixty adolescents with epilepsy and their caregivers completed the Allocation of Treatment Responsibility Scale and a battery of self-report measures. Medical chart review data and electronically monitored AED adherence were collected for 1 year. Descriptive data assessed ATR for caregivers and adolescents; multivariate hierarchical regressions tested associations between variables.

Results

ATR for labs and clinic appointments was greatest for caregivers, while ATR for AEDs was more likely to be shared between caregiver and adolescent. Poorer attention was associated with greater caregiver responsibility for AEDs. Greater caregiver responsibility for AEDs was associated with higher electronically monitored adherence over 12 months.

Conclusions

In adolescents with epilepsy, caregivers are responsible for most treatment tasks, although responsibility for taking medication was shared with the adolescent. Greater caregiver responsibility for medication results in better long-term AED adherence. ATR is an important construct that warrants further attention in research and clinical practice, especially in the context of transition and health outcomes in pediatric epilepsy.

A Systematic Review of Behavioral Intervention Technologies for Youth With Chronic Health Conditions and Physical and Intellectual Disabilities: Implications for Adolescents and Young Adults With Spina Bifida

OBJECTIVE

Behavioral intervention technologies (BITs) stand as a promising delivery mechanism that overcomes multiple condition-specific and access barriers for self-management interventions for adolescents and young adults with spina bifida (AYA-SB). The purpose of the current review was to synthesize the behavioral and self-management intervention literature in conditions that have overlapping symptoms with youth with SB and to develop a model of likely user needs for AYA-SB that promotes self-management.

METHOD

The search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) databases. The review was based on a systematic narrative synthesis framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092342).

RESULTS

In total, 18 articles were included in the current BIT review. The majority of included studies (1) targeted the management of chronic health conditions, (2) were informed by evidence-based approaches, (3) relied on content delivery, (4) were Web-based, (5) used linear or user-driven workflows, (6) included professional human support, and (7) included a control condition.

CONCLUSIONS

Many of the evaluated BITs resulted in acceptable usage and maintained or improved targeted symptoms. A user needs model for AYA-SB is proposed with the intention that future research will promote further refinement and ultimate deployment of a BIT for AYA-SB to promote self-management.

Technology usage and barriers to the use of behavioral intervention technologies in adolescents and young adults with spina bifida

PURPOSE

The majority of behavioral intervention technologies (BITs) have been designed and targeted towards the general population (i.e., typically-developing individuals); thus, little is known about the use of BITs to aid those with special needs, such as youth with disabilities. The current study assessed adolescents and young adults with spina bifida (AYA-SB) for: 1) their technology usage, and 2) anticipated barriers to using technology to help manage their health.

METHODS

AYA-SB completed a survey of their media and technology usage. A card sorting task that ranked and grouped anticipated barriers to using a mobile app to manage health was also completed. Ranked means, standard deviations, and the number of times a barrier was discarded were used to interpret sample rankings.

RESULTS

AYA-SB reported less frequent technology and media use than the general population. However, differences emerged by age, with young adults endorsing higher usage than their younger counterparts. Top concerns focused on usability, accessibility, safety, personal barriers due to lack of engagement, technological functioning, privacy, and efficacy.

CONCLUSIONS

AYA-SB appear to be selective users of technology. It is therefore critical that the design of BITs address their concerns, specifically aiming to have high usability, accessibility, and engagement.

Moderators of Internet-Delivered Cognitive-Behavioral Therapy for Adolescents With Chronic Pain: Who Benefits From Treatment at Long-Term Follow-Up?

Cognitive behavioral therapy (CBT) is effective for pediatric chronic pain, but little is understood about which youth are most likely to benefit. The current study aimed to identify individual characteristics for which CBT yielded the greatest (and least) clinical benefit among adolescents with chronic pain participating in a multicenter randomized controlled trial of Internet-delivered CBT (WebMAP2). A total of 273 adolescents ages 11 to 17 with chronic pain (M age = 14.7; 75.1% female) were randomly assigned to Internet-delivered CBT or Internet-delivered pain education and evaluated at pretreatment, post-treatment, and 2 longer term follow-up periods (6 and 12 months). Multilevel growth models tested several adolescent- and parent-level moderators of change in pain-related disability including 1) adolescent age, sex, pain characteristics, distress, and sleep quality and 2) parent education level, distress, and protective parenting behavior. Younger adolescents (ages 11-14; vs older adolescents ages 15-17) and those whose parents experienced lower levels (vs higher levels) of emotional distress responded better to Internet CBT treatment, showing greater improvements in disability up to 12 months post-treatment. This study expands knowledge on who benefits most from Internet-delivered psychological treatment for youth with chronic pain in the context of a large multicenter randomized controlled trial, suggesting several avenues for maximizing treatment efficacy and durability in this population. PERSPECTIVE: This study identified adolescent- and parent-level predictors of treatment response to Internet-based CBT for pediatric chronic pain up to 12 months later. Younger adolescents and those whose parents had lower levels of distress may particularly benefit from this intervention. Older adolescents and those whose parents exhibit higher distress may require alternative treatment approaches.

Rebellious Behaviors in Adolescents With Epilepsy

Objectives

The study aims are to (1) examine the prevalence of risk-taking (i.e., behaviors that can be categorized as rebellious or reckless) and (2) determine the influence of risk-taking on adherence, seizures, and health-related quality of life (HRQOL) in adolescents with epilepsy. An exploratory aim was to identify predictors of risk-taking.

Methods

Fifty-four adolescents with epilepsy (M = 15.33 ± 1.46 years) and caregivers completed questionnaires on demographics, risk-taking, parent-child relations, adolescent inattention/hyperactivity, and HRQOL at four time points across 1 year. Seizure occurrence and electronically monitored adherence were also collected.

Results

Rebellious behaviors were normative and stable over 1 year in adolescents with epilepsy. Higher rebelliousness was related to poorer adolescent-reported memory HRQOL. The only significant positive predictor of rebellious behaviors was adolescent age.

Conclusions

Adolescents with epilepsy endorsed normative levels of rebelliousness, which is negatively related to HRQOL. Older adolescents may warrant clinical attention.

Clustered randomized controlled trial of a clinic-based problem-solving intervention to improve adherence in adolescents with cystic fibrosis

BACKGROUND

In Cystic Fibrosis (CF), adherence to pulmonary medications is about 50% and decreases during adolescence. Effective interventions have not been integrated into CF care. This effectiveness study tested a brief, clinic-based behavioral intervention to improve adherence.

METHODS

iCARE (I Change Adherence and Raise Expectations) was a pragmatic, clustered, 2-arm randomized controlled trial at 18 CF Centers. 607 adolescents with CF, ages 11-20 years, participated. Centers were randomized to IMPACT (n = 9; 300 adolescents), a brief problem-solving + education intervention, or standard care (SC; n = 9; 307 adolescents). IMPACT was delivered during a regularly scheduled clinic visit by a member of the clinical care team. The primary outcome was composite pulmonary medication possession ratio (cMPR); secondary endpoints were lung function, Body Mass Index percentile, courses of IV antibiotics, and health-related quality of life at 12 months.

RESULTS

Effectiveness of the intervention was tested using mixed models, generalized estimating equations comparing IMPACT to SC. Fifty-eight percent of problem-solving sessions targeted barriers to airway clearance, exercise or nutrition, while 18% addressed pulmonary medications. Average intervention fidelity score was 67% (SD = 14%; Range = 25-100%). No significant intervention effects were found for cMPR or any of the secondary outcomes compared to SC.

CONCLUSIONS

The IMPACT intervention did not improve medication adherence or health outcomes over 12 months. Challenges to implementing the intervention as intended during busy clinic visits were identified.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01232478; URL: www.clinicaltrials.gov.

Living with epilepsy in adolescence-A qualitative study of young people's experiences in Singapore: Peer socialization, autonomy, and self-esteem

BACKGROUND

Systematic reviews of quantitative research on the effects of childhood epilepsy have established its association with higher levels of psychiatric diagnosis, externalizing and internalizing problems, lower health-related quality of life, social competence, and poorer academic achievements, compared with their peers. However, much less is known about young people's experiences of living with epilepsy and its impact on their development from their own perspectives.

METHODS

Semistructured interviews were conducted with 15 young people aged between 13 and 16 years. Participants were recruited as part of a larger mixed methods study examining individual and family influences on outcomes for young people with epilepsy. These young people attended an epilepsy clinic in KK Women's and Children's Hospital, Singapore. The framework approach to data management and analyses involved both inductive and deductive generation of themes.

RESULTS

Findings from young people's interviews provided in-depth descriptions of stressful circumstances encountered. Interconnectedness between severity of the impairment and its impact on key developmental tasks, such as independence, autonomy, and social development, were emphasized. Seizures and illness-related demands disrupted their day-to-day functioning and challenged their abilities to meet these tasks. In addition to these impairment effects, young people's experiences of social exclusion were also affected by social and environmental factors, which act as systemic barriers to participation. In turn, this has an effect on their self-esteem. Nevertheless, young people reported positive experiences, such as support from both family and friends, which served as protective factors against the stress of living with a chronic medical condition.

CONCLUSION

The demands of epilepsy affect various domains of young people's lives. In order to obtain a holistic understanding of young people's inclusion or exclusion to participation, it is necessary to consider impairment effects, barriers to doing, and barriers to being.

Parent Perceptions of Their College Students' Self-Management of Attention-Deficit/Hyperactivity Disorder

PURPOSE

The present study examines parents' perspectives of the experiences and challenges surrounding self-management of Attention-Deficit/Hyperactivity Disorder (ADHD) in their college students.

METHODS

Participants were parents of emerging young adults with ADHD prescribed daily medication for their condition. Thirteen individual interviews were conducted using a semistructured interview script guided by the Health Belief Model. The qualitative data were analyzed via directed content analysis.

RESULTS

Five themes emerged from the interviews: (1) parents are heavily involved in their child's self-management prior to college, and the abrupt transition of responsibilities is difficult for parents; (2) parents' worries about their child's self-management and functioning are exacerbated by privacy laws and poor communication from child and university; (3) volitional nonadherence is high; (4) obtaining academic accommodations is difficult; and (5) parents recommend a gradual transition, desire enhanced communication from the college, and wish for social support resources in the college setting for their children.

CONCLUSIONS

Parents of college students with ADHD are distressed and frustrated by the transition to college. They express the desire to remain continually involved in their child's self-management of ADHD, but several barriers hinder their ability to do so, resulting in fear of the potential consequences on their child's functioning. This collateral information from parents regarding the challenges associated with ADHD self-management experiences in college should result in the development of comprehensive interventions to improve the quality of life in college students with ADHD.

The Epidemiology of Transition into Adulthood of Rare Diseases Patients: Results from a Population-Based Registry

Background: Despite the fact that a considerable number of patients diagnosed with childhood-onset rare diseases (RD) survive into adulthood, limited information is available on the epidemiology of this phenomenon, which has a considerable impact both on patients' care and on the health services. This study describes the epidemiology of transition in a population of RD patients, using data from the Veneto Region Rare Diseases Registry (VRRDR), a web-based registry monitoring since 2002 a consistent number of RD in a defined area (4.9 million inhabitants). Methods: Longitudinal cohorts of patients born in the years 1988 to 1998 and enrolled in the VRRDR in their paediatric age were identified. Data referred to this group of patients, experiencing transition from paediatric to adult age during the years 2006⁻2016, are presented. Results: 2153 RD patients (44.1% females and 55.9% males) passed from childhood to adulthood in the study period, corresponding to a 3-fold increase from 2006 to 2016. The majority of these patients was affected by congenital anomalies (32.0%), by hematologic diseases (15.9%), eye disorders (12.1%) and neoplasms (7.9%). RD patients who experienced transition from paediatric age to adulthood represent the 9.2% of adult patients enrolled in the Registry at 31 December 2016. Conclusions: We described a subset of RD young adults experiencing transition into adulthood. The data reported can be considered as minimum values for estimating the size of this increasing population presenting specific transition needs. These figures are valuable for clinicians, patients and health planners. Public policy interventions are needed in order to promote dedicated care transition pathways in the broader framework of health policies devoted to RD.

Psychosocial outcomes in a cohort of perinatally HIV-infected adolescents in Western Jamaica

BACKGROUND

Psychosocial factors interact with adolescent development and affect the ability of HIV-infected adolescents to cope with and adhere to treatment.

AIM

To evaluate psychosocial outcomes in perinatally HIV-infected adolescents (PHIVAs) in Western Jamaica after psychosocial intervention.

METHODS

The Bright Futures Paediatric Symptom Checklist (BF-PSC) was used for psychological screening of PHIVAs in Western Jamaica. Referred patients were evaluated using the Youth version of the Columbia Impairment Scale (CIS). Demographic, laboratory and clinical data obtained between July 2014 and June 2016 were evaluated retrospectively and outcomes were reviewed before and after psychosocial intervention.

RESULTS

Sixty PHIVAs were enrolled and 36 (60%) had a positive BF-PSC score that necessitated referral. The BF-PSC correctly identified 89% of patients with impaired psychosocial assessment by CIS scores. Referred patients were less likely to adhere to treatment, to be virologically suppressed or to have a CD4+ count of >500 cells/μl, and were more likely to be in the late teenage group or to be of orphan status. After intervention, the prevalence of viral suppression increased and median viral load decreased. A difference in mean CD4+ cell count was detected before but not after intervention in teenage and orphan groups.

CONCLUSIONS

The BF-PSC identified at-risk PHIVAs with impaired psychosocial functioning. Increased vulnerability was noted in orphans and older teenagers. Psychosocial interventions (including family therapy) reduced psychosocial impairment and improved virological suppression. Mental health intervention should be instituted to facilitate improved clinical outcomes, autonomy of care and transition to adult care.

Impact of home spirometry on medication adherence among adolescents with cystic fibrosis

OBJECTIVE

Medication adherence among adolescents with cystic fibrosis (CF) is often suboptimal and this has significant impact on their health and quality of life. The purpose of the study was to evaluate the impact of frequent home pulmonary function (PFT) monitoring on medication adherence among adolescents with CF.

HYPOTHESIS

We hypothesized that weekly home PFT monitoring will improve adherence while not significantly adding to the treatment burden.

METHODS

Individuals aged 12-21 years with CF were provided a spirometer to measure PFTs weekly for 1 year. Results were reviewed weekly via telephone. PFT data were downloaded from the device during quarterly clinic visits. Adherence was calculated from prescription refill data and compared to the previous year. Perceptions of treatment burden were assessed using the CF questionnaire-revised (CFQ-R) quality of life measure. Health outcome measures including nutritional status and PFTs from clinic were collected for the study period and the year prior.

RESULTS

Thirty-nine subjects participated in the study. Mean age was 15.89 ± 2.18 years and 54% were female. Mean adherence to weekly spirometry monitoring was 59.47 ± 24.60%. Values generated on the device showed good correlation with those obtained in clinic. Mean medication possession ratio (MPR) was 60% in the previous year and 65% during the study (P = 0.04). Mean treatment burden scaled score on the CFQ-R was 68 at enrollment and 66 at study completion (P = 0.14).

CONCLUSIONS

Frequent home PFT monitoring is feasible in CF adolescents and could successfully improve medication adherence without significantly impacting treatment burden.

Adherence to antiepileptic drugs in adolescents with epilepsy

INTRODUCTION

The aims of the current study were to identify patterns and predictors of adherence in adolescents with epilepsy over one year, as well as its impact on seizures and health-related quality of life (HRQOL).

METHODS

Forty-eight adolescents with epilepsy (M_age=14.8+1.5, 69% female, 73% White: NonHispanic) and their caregivers completed questionnaires assessing demographics, epilepsy knowledge, side effects, adherence barriers, family functioning, and HRQOL at quarterly clinic visits over one year. Adherence was monitored electronically via MEMS TrackCaps. Seizures were determined via chart review.

RESULTS

Baseline adherence was 86.05% and significantly decreased over 12months (b=-2.07, p<0.001). Higher adherence was predicted by higher socioeconomic status (SES) (b=0.04, p<0.05), more side effects (b=0.06, p<0.01), fewer caregiver-reported adherence barriers (b=0.18, p<0.05), and lower family conflict (b=-0.19, p<0.05). Change in adherence over 12months did not significantly predict HRQOL or seizures.

CONCLUSIONS

This is the first longitudinal study of objective adherence in adolescents with epilepsy. Given adolescence is a period of vulnerability during development, including declining adherence, caregivers are encouraged to continue collaborating with their adolescents around epilepsy management. Adherence barriers represent an ideal target for intervention and can be implemented in the clinic by frontline providers. Multidisciplinary care can address low SES (social work, financial advocates) and family conflict (psychologists, therapists) in patients with the ultimate goal of optimizing adherence and health outcomes.

Parent knowledge of disease management in cystic fibrosis: Assessing behavioral treatment management

BACKGROUND

Cystic fibrosis (CF) is a life-shortening, burdensome disease requiring complex knowledge to manage the disease. Significant gaps in knowledge have been documented for parents, which may lead to unintentionally poor adherence and insufficient transfer of treatment responsibility from parents to adolescents. There are no current, validated measures of parent knowledge for this population and there are no measures that assess the knowledge required for day-to-day behavioral management of CF. We assessed the psychometric properties of the parent version of the Knowledge of Disease Management-Cystic Fibrosis measure (KDM-CF-P) using data from iCARE (I Change Adherence and Raise Expectations), a randomized control adherence intervention trial.

METHODS

A total of 196 parents in the iCARE standard care/control arm completed 35 items assessing their knowledge of disease management at their 12-month study visit, prior to beginning the intervention. Items were eliminated from the measure if they met the threshold for ceiling effects, were deemed clinically irrelevant, or did not correlate well with their intended scale. Item-to-total correlations, confirmatory factor analysis, discriminant function, reliability, and convergent validity were calculated.

RESULTS

The KDM-CF-P (19 items) demonstrated internal consistency of KR20 = 0.60 on each scale and a two-scale structure. Convergent validity for knowledge scores was found with maternal education, family income, and type of medical insurance. Parents correctly answered approximately 85% of items on the KDM-CF-P.

CONCLUSIONS

The KDM-CF-P psychometrics support a two-scale measure with clinical utility. It is useful for assessing gaps in knowledge that can be remediated through individualized, tailored interventions.

Understanding Treatment Adherence With the Health Belief Model in Children With Cystic Fibrosis

Objective. Children’s health beliefs are significantly related to their adherence; however, pediatric literature has rarely tested health-related theories as a whole. The goal of the present study was to evaluate the use of the health belief model (HBM) in understanding children’s adherence, both globally and to individual treatment components. Method. Thirty-three patient–parent dyads completed questionnaires regarding health beliefs and adherence to medical regimens. Results. Multiple linear regressions found a significant relationship among the HBM variables and reports of global adherence for children and parents. For children, the HBM variables were significantly related to adherence to aerosol medications, aerosol antibiotics, metered dose inhalers, and vitamins. For parents, the HBM variables were significantly related to children’s adherence to airway clearance, oral antibiotics, and vitamins. Paired sample t tests found children and parents had significantly discrepant heath beliefs. Conclusion. These findings provide further support for the HBM in evaluating pediatric adherence, with evidence that barriers and cues to action may be targets for early intervention. Future research using this model to identify a comprehensive way to assess, understand, and elicit change in the adherence to medical regimens for youth with chronic illness would be beneficial.

Adherence and barriers to hyperinsufflation in children with congenital muscular dystrophy

BACKGROUND

Congenital muscular dystrophy (CMD) is a rare, inherited neuromuscular disease characterized by progressive muscle weakness, thoracic insufficiency, and ultimately respiratory failure. Adherence to respiratory therapies in children with neuromuscular disorders is unknown. This study examined the multimodal assessment of adherence and barriers to 15 min, twice daily hyperinsufflation in children with CMD. Adherence was hypothesized to be greater than 50% and discomfort, embarrassment, and difficulty finding time were hypothesized to be barriers.

METHODS

Participants included 18 children with CMD. Personalized hyperinsufflation settings were determined based on pressure-volume measurements at each study visit. Adherence was measured by a daily phone diary (DPD) and by electronic data download from the hyperinsufflation device. The DPD was conducted twice over a 48-hr period to capture a weekend and weekday, with the goal being 60 min of hyperinsufflation over the 48 hr (100% adherence). The hyperinsufflation objective electronic data reflected daily use of hyperinsufflation for the same 48-hr period. Data from DPD and the corresponding hyperinsufflation device data were used for analyses.

RESULTS

Adherence to hyperinsufflation was 40% via DPD and 44% for electronic data, with strong convergence between methods (r = 0.75, P < 0.001). Surprisingly, 53% of participants reported no barriers despite low adherence. Social distractions and family obligations were identified as barriers. There were no differences in adherence between those who did and did not endorse barriers to hyperinsufflation (DPD: t(13) = 0.44, P = n.s.; hyperinsufflation device: t(13) = -0.23, P = n.s.).

CONCLUSION

Adherence to hyperinsufflation is a significant problem in children with CMD and families have difficulty identifying adherence barriers. An important next step is to encourage open dialog around adherence barriers and promote adherence behaviors via intervention. Pediatr Pulmonol. 2017; 52:939-945. © 2016 Wiley Periodicals, Inc.

Different Demands, Same Goal: Promoting Transition Readiness in Adolescents and Young Adults With and Without Medical Conditions

PURPOSE

This study aimed to examine differences in transition readiness, self-involvement and parental involvement in completing medical tasks, and general self-efficacy between a sample of older adolescents and young adults (AYAs) with medical conditions and a sample of healthy peers. Relations among these variables were also examined.

METHODS

The sample included 494 AYAs (mean age = 19.30 years, standard deviation = 1.33) who reported on their levels of transition readiness, self-involvement and parental involvement in completing medical tasks, and general self-efficacy.

RESULTS

AYAs with medical conditions reported significantly higher levels of transition readiness and self-involvement in completing medical tasks and lower levels of parent involvement in completing medical tasks than healthy peers. Parent involvement in completing medical tasks indirectly related to transition readiness through AYA self-involvement in completing medical tasks for both AYAs with medical conditions and healthy peers.

CONCLUSIONS

AYAs with medical conditions appear to have greater transition readiness skills and demonstrate more independence in completing medical tasks than healthy peers. For AYAs with medical conditions and healthy peers, transition readiness appears to be enhanced as parents decrease their involvement in completing AYAs' medical tasks and AYAs increase self-involvement in completing these tasks. AYAs with medical conditions, as well as healthy peers, may benefit from programming delivered in primary care, specialty clinic, or educational settings that focuses on increasing AYAs' involvement in and responsibility for managing their health care.

A Qualitative Analysis of the Information Needs of Parents of Children with Cystic Fibrosis prior to First Admission

PURPOSE

Hospitalization can be stressful for patients and their families. Pre-hospitalization information is crucial in establishing a good basis for patient satisfaction. In order to develop better preparatory material for parents, this qualitative study explored whether parents of children with cystic fibrosis, admitted to a UK Children's Hospital, felt adequately prepared for their child's admission.

DESIGN AND METHODS

Data were collected from twelve parents whose children had been admitted within the last two years for routine intravenous antibiotics. Semi-structured interviews were analyzed using thematic analysis.

RESULTS

Four themes emerged from the analysis: (1) preparing for admission, (2) the ward as a challenging environment, (3) changes in the parent-professional relationship and (4) the parental role in medical care.

CONCLUSION

Provision of adequate preparatory information is essential in reducing parental stress, influencing how future experiences are appraised and managed. Effective parent-professional communication and opportunities to participate in care are likely to improve parental satisfaction.

PRACTICE IMPLICATIONS

Preparatory information prior to hospital admission greatly assists parents in making informed decisions and working as joint advocates in their child's inpatient care.

Exploring Transition to Self-Management Within the Culture of Sickle Cell Disease

Purpose: The aim of this study was to explore the meaning of transition to self-management in sickle cell disease. Design/Method: Twelve audio-recorded semistructured interviews were conducted with a sample of 21- to 25-year-olds recruited from a comprehensive sickle cell center in the northeast region of the United States. Data were analyzed using an existential framework according to van Manen’s phenomenological method. Findings: The meaning of transition to self-management was found in lived time, space, body, and human relationship. The emerging themes highlighted in this article include: Best Mother Ever, Growing up in the Hospital, I’m Not Trying that Again, Doing it on My Own, Living Day-by-Day, and Not a Kid any Longer. The themes reflected meaning and insight into this unique experience. Conclusion/Practice Implications: Study results emphasize the culturally constructed meaning of transition to sickle cell disease self-management and need to integrate transcultural perspectives into nursing practice to support this emerging phenomenon.

Parental Depression and Pancreatic Enzymes Adherence in Children With Cystic Fibrosis

BACKGROUND

Treatment adherence in cystic fibrosis (CF) is often poor, however, less is known about adherence to pancreatic enzymes, a critical component of the CF treatment regimen. Parent caregivers often report elevations in depression, and parental depression may adversely affect children's adherence.

METHODS

This prospective study evaluated adherence to pancreatic enzymes in 83 patients (1-13 years) . Adherence was measured across 3 months with electronic pill-caps . Weight was measured at baseline and a 3-month follow-up. Parental depressive symptoms were evaluated by using the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Adherence to pancreatic enzymes was 49.4% ± 3.4%. Adherence was higher at school (94.4% ± 6.1%) than at home (42.3% ± 3.1%), and higher for toddlers (50.6% ± 5.2%) than for school-aged children (37.5% ± 3.7%). Parents reported high rates of depressive symptoms (30% in the clinical range, 18% with moderate symptoms). Children of parents with symptoms of depression versus those without were less adherent (34.8% ± 4.5% vs 48.5% ± 4.1%), and adherence to enzymes was significantly related to 3-month weight outcomes. Average gain in weight z scores across 3 months was 0.5 ± 0.2for children who were >50% adherent and -0.1 ± 6.1for children who were <33% adherent. Parental depression had a signifcant, indirect effect on weight via adherence (-0.005 ± 0.003 gain in weight z score per CES-D unit ).

CONCLUSIONS

High rates of parental depressive symptoms, coupled with its negative effects on adherence, suggest that measuring and treating parental depression may improve children's adherence to therapy.

Parent-to-Child Transition in Managing Cystic Fibrosis: A Research Synthesis

Although parents and children must adhere to five primary treatments for cystic fibrosis (CF), and their roles transition over time, the scope of CF studies often has been limited to one treatment regimen or to children within a specified age range. The purpose of this mixed research synthesis study is to integrate findings from qualitative and quantitative studies addressing the transition of CF management from parent to child, as well as factors related to adherence across treatments and over time. An existing grounded theory was used as a framework to synthesize findings in 17 reports from 16 studies. The results confirm the theory and posit three additional factors that may influence parent-to-child transition of care management.

An examination of the Allocation of Treatment Responsibility scale in adolescents with epilepsy

The purpose of the current study was to examine the psychometric properties of the adapted Allocation of Treatment Responsibility (ATR) scale and the distribution of tasks related to oral medication and clinic and laboratory visits in a sample of adolescents with epilepsy. Adolescents with epilepsy (N = 50; ages 13-17 years) and their caregivers completed the adapted ATR and a measure of medication management. Internal consistency for the adapted ATR was strong (total and subscale range: 0.75-0.97). Validity was partially supported by significant correlations between adolescent age and ATR oral medication responsibility for both respondent measures. Allocation of Treatment Responsibility total scores were not associated with adherence to medications and clinic appointments. Initial findings are promising and have important implications for assessing the distribution of treatment responsibility among adolescents with epilepsy and their families.

Predictors of non-adherence to follow-up visits and deferasirox chelation therapy among jordanian adolescents with Thalassemia major

Poor adherence to treatment can have negative effects on outcomes and heath care cost. However, little is known about the factors that impact adherence to deferasirox chelation therapy. The aims of this study were to identify rates and predictors of non-adherence to medical regimen among thalassemia major adolescents on deferasirox oral chelation therapy by using subjective (self-reporting) and objective (serum ferritin and follow-up visits) measures. Convenient samples of 164 adolescents, aged 12-19 years were recruited from three National Thalassemia Centers in Jordan. Patients were interviewed using a four-section questionnaire and the medical records were checked. Results indicated that rate of adherence according to self-report was (73%); while to follow-up medical appointments and serum ferritin level rates was 57% and 47%, respectively. One-third of participant adolescents (n = 52) were psychologically impaired. Multivariate analysis showed that factors affecting adolescent non-adherence to deferasirox chelation therapy is different from that affecting adherence to follow-up visits. In general, adolescents more than 16 years old, presence of sibling with thalassemia, lack of parental monitoring, lower family income, decrease frequency of blood transfusion, and psychological impairment were found significant predictors of non-adherence among adolescents. Disease knowledge was not associated with adherence status of the adolescents. Clinician should be aware of high prevalence of low adherence to chelation therapy during adolescent years. Nurses need to regularly assess, monitor, and promote adherence behavior that might impact patients' outcomes.

Pulmonary medication adherence and health-care use in cystic fibrosis

BACKGROUND

Poor treatment adherence is common in cystic fibrosis (CF) and may lead to worse health outcomes and greater health-care use. This study evaluated associations of adherence to pulmonary medications, age, health-care use, and cost among patients with CF.

METHODS

Patients with CF aged ≥ 6 years were identified in a national commercial claims database. A 12-month medication possession ratio (MPR) was computed for each pulmonary medication and then averaged for a composite MPR (CMPR) for each patient. The CMPR was categorized as low (< 0.50), moderate (0.50-0.80), or high (≥ 0.80). Annual health-care use and costs were measured during the first and second year and compared across adherence categories by multivariable modeling.

RESULTS

Mean CMPR for the sample (N = 3,287) was 48% ± 31%. Age was inversely related to CMPR. In the concurrent year, more CF-related hospitalizations were observed among patients with low (event rate ratio [ERR], 1.35; 95% CI, 1.15-1.57) and moderate (ERR, 1.25; 95% CI, 1.05-1.48) vs high adherence; similar associations were observed for all-cause hospitalizations and CF-related and all-cause acute care use (hospitalizations + ED) in the concurrent and subsequent year. Rates of CF-related and all-cause outpatient visits did not differ by adherence. Low and moderate adherence predicted higher concurrent health-care costs by $14,211 ($5,557-$24,371) and $8,493 (-$1,691 to $19,709), respectively, compared with high adherence.

CONCLUSIONS

Worse adherence to pulmonary medications was associated with higher acute health-care use in a national, privately insured cohort of patients with CF. Addressing adherence may reduce avoidable health-care use.

The impact of medication adherence on lung health outcomes in cystic fibrosis

PURPOSE OF REVIEW

As new medications continue to come to market to improve health in individuals with cystic fibrosis (CF), patient adherence is increasingly more important to address. Currently, adherence for pulmonary medications is approximately 50% for people with CF. There has been recent research that has demonstrated that poor adherence is linked to worse health outcomes. This review summarizes recent research on the impact of adherence on lung health and highlights future areas of research and clinical practice to address this growing need.

RECENT FINDINGS

Recent research has indicated that nonadherence is associated with increased hospitalizations and pulmonary exacerbations, lower baseline lung function, and longer length of stays. However, most of the research has been done using pharmacy refill records as an objective measure of adherence. Electronic monitoring of medications provides more detailed information about patterns of use, which can directly inform clinical care. Furthermore, there have been few published clinical trials evaluating behavioral interventions to promote adherence.

SUMMARY

Given the recent research linking adherence to lung health outcomes, there is a growing need to measure and evaluate adherence in clinical care. As new medications are approved for CF, methods to monitor adherence also need to be developed and approved. Clinicians need to continue to assess barriers to adherence to be able to individually tailor interventions to a patient's needs.

Longitudinal stability of specific barriers to medication adherence

OBJECTIVE

Higher levels of barriers are related to lower medication adherence and negative medical outcomes in pediatric transplant recipients. Although total number of barriers appears to be stable over time, it is unclear whether the same is true for specific barriers. This study examined the frequency of endorsement and the stability of specific barriers over 18 months.

METHOD

Participants included 63 parents and 51 adolescents and young adults. Transplant types included 39 kidneys, 16 livers, 10 hearts, and 1 double lung. Participants completed measures of perceived barriers to adherence at Time 1 (T1) and Time 2 (T2).

RESULTS

The majority of parent- and adolescent-reported specific barriers showed a positive relationship from T1 to T2. Few specific barriers showed significant differences in the level of endorsement between time points.

CONCLUSION

Specific barriers to medication adherence tend to be stable over time. Patients' specific barriers appear unlikely to change without targeted intervention.