Reported Problems and Adherence in Using Asthma Medications Among Adolescents and Their Caregivers

Impact of the COVID-19 Pandemic on Lung Function and Treatment Decisions in Children with Asthma: A Retrospective Study

Background/Objectives: Asthma outcomes in children and adolescents largely depend on parental adherence to prescribed treatment plans. This study investigates how the COVID-19 pandemic influenced parental decision-making in managing their children's asthma, regardless of whether the children were infected with SARS-CoV-2. Material and method: In this research, 146 children with asthma were analyzed based on the following data: demographic parameters (gender, age group, and residence), before and after measurements of FeNO and pulmonary function test parameters were performed to assess the evolution of asthma for infected and non-infected children, exacerbations, parents' compliance with the treatment, changes in treatment steps performed by physicians, and the GINA asthma control levels. Results: The effect of parent self-management of doses was evident in the variation of FeNO and pulmonary function test parameters before and after COVID-19 disease, including children with asthma who did not contract the virus, in the decrease in well-controlled asthma cases, as well as in the number of exacerbations per year. A step-down in treatment doses was statistically associated with increased FeNO values (p < 0.0005), and decreased FEV1 values (p = 0.025). Higher values of FeNO were statistically significantly associated with a higher number of exacerbations per year (p < 0.0005). There was a statistically significant moderately strong association between the treatment steps evolution (decided by the attending physician) and parents' self-management of doses in the attempt to assess the control of the disease of children with asthma (p = 0.019). Also, 80.95% of children for whom the parents performed a step-down in dose no longer presented well-controlled asthma, leading to a statistically significant association relative to the level of asthma control and doses adjustments (p < 0.0005). Conclusions: During epidemiological circumstances, a strong collaboration between the parents/caregivers/pediatric patients with asthma and attending physicians is essential to correctly assess the symptoms and to comply the asthma treatment with ICS and a bronchodilator in order to control the disease.

Caregiver's sense of coherence and adherence to paediatric asthma treatment

Asthma is a chronic respiratory condition that needs to be well controlled to avoid compromising patients' quality of life. In the paediatric population, the role of caregivers is essential in this process. Moreover, adequate asthma control is integral to a child's emotional well-being and to improving the child's ability to participate fully in family and social life. One of the main reasons for uncontrolled asthma is low adherence to treatment, by patients and caregivers. Identifying factors mediating the involvement and participation of caregivers through evaluations of caregivers' sense of coherence can help in the adoption of strategies aimed at effectively directing adherence behaviour through educational and motivational interventions. The goal of this review article is to provide an overview of the sense of coherence as a construct of Antonovsky's salutogenic theory, and to identify its role as a key piece in the successful management of asthma in children.

The Uniformed Services Constipation Action Plan: An Effective Tool for the Management of Children with Functional Constipation

OBJECTIVE

To implement and to evaluate the effectiveness of the Uniformed Services Constipation Action Plan (USCAP) in our gastroenterology clinic for children with functional constipation.

STUDY DESIGN

This implementation science study included toilet-trained subjects aged 4 years and older who met the Rome IV criteria for functional constipation. Children were block randomized to receive either the USCAP or control. All clinic functional constipation plans recommended subjects continue pharmacotherapy for 4 months. Endpoints measured were clinical outcomes (resolution of functional constipation and achievement of a Pediatric Bristol Stool Form Scale [PBSFS] score of 3 or 4), patient-related outcomes (health-related quality of life [HRQoL] total scale score), and health confidence outcomes (Health Confidence Score [HCS]).

RESULTS

Fifty-seven treatment group subjects (44%) received a USCAP (52% male; mean age, 10.9 [4.9] years) compared with 73 controls (56%; 48% male; mean age,10.9 [5.3] years). A PBSFS score of 3 or 4 was achieved by 77% of the treatment group compared with 59% of controls (P = .03). Subjects from the treatment group were more likely than the controls to endorse adherence to the 4-month course of pharmacotherapy (P < .001). Subjects who received a USCAP had greater improvements in HRQoL total scale score by the end of the project (P = .04).

CONCLUSIONS

The USCAP is a simple, inexpensive tool that has the potential to improve global outcomes for functional constipation in children and should be recommended as standard clinical practice.

Medication Adherence and Common Barriers for Caregivers of Preschool Children with Pediatric Glaucoma

Purpose. To investigate the medication adherence among caregivers of preschool children with pediatric glaucoma and to elucidate common barriers leading to poor adherence. Methods. A cross-sectional study. Caregivers of preschool children with pediatric glaucoma completed a questionnaire on demographic information of caregivers, demographic and disease characteristics of children, caregivers-reported medication adherence (by an adapted Morisky Adherence Scale), and possible 13 barriers. Results. Overall 132 questionnaires were considered valid. Thirty-six percent of all reported poor medication adherence. Caregivers’ age and self-evaluated knowledge about pediatric glaucoma showed a significant difference between the adherent and nonadherent groups ( $P<0.05$ ). Nineteen percent of all reported only one barrier as important, 65% cited multiple barriers, and 16% cited no barriers. Anxiety and depression were cited as important by most caregivers in both groups. Univariate logistic regression analysis demonstrated that difficulty with the acquisition of medications (OR, 2.5; 95% CI, 1.1–5.7; $P=0.025$ ), difficulty with medication schedule (OR, 2.3; 95% CI, 1.0–5.0; $P=0.043$ ), and high expenses for medications (OR, 4.8; 95% CI, 1.4–15.9; $P=0.011$ ) were significantly associated with higher odds of poor adherence. Conclusions. Over one-third of caregivers of preschool children with pediatric glaucoma were in poor medication adherence. Nearly two-thirds of caregivers cited multiple barriers simultaneously as important hindrances to medication usage. Anxiety and depression, difficulty with the acquisition of medications, difficulty with the medication schedule, and high expenses for medications were prominent barriers. Individualized solutions should be provided according to reported barriers by each caregiver and the other most common barriers.

Visualizing the knowledge domains and research trends of childhood asthma: A scientometric analysis with CiteSpace

Background

Asthma is one of the most common chronic diseases in children globally. In recent decades, advances have been made in understanding the mechanism, diagnosis, treatment and management for childhood asthma, but few studies have explored its knowledge structure and future interests comprehensively.

Objective

This scientometric study aims to understand the research status and emerging trends of childhood asthma.

Methods

CiteSpace (version 5.8.R3) was used to demonstrate national and institutional collaborations in childhood asthma, analyze research subjects and journal distribution, review research keywords and their clusters, as well as detect research bursts.

Results

A total of 14,340 publications related to childhood asthma were extracted from Web of Science (core database) during January 2011 to December 2021. The results showed that academic activities of childhood asthma had increased steadily in the last decade. Most of the research was conducted by developed countries while China, as a developing country, was also actively engaged in this field. In addition to subjects of allergy and immunology, both public health aspects and ecological environmental impacts on the disease were emphasized recently in this research field. Keywords clustering analysis indicated that research on asthma management and atopy was constantly updated and became the two major research focuses recently, as a significant shift in research hotspots from etiology and diagnosis to atopic march and asthma management was identified. Subgroup analysis for childhood asthma management and atopy suggested that caregiver- or physician-based education and interventions were emerging directions for asthma management, and that asthma should be carefully studied in the context of atopy, together with other allergic diseases.

Conclusions

This study presented a comprehensive and systematic overview of the research status of childhood asthma, provided clues to future research directions, and highlighted two significant research trends of asthma management and atopy in this field.

Lung Function Tests, Quality of Life and Telemedicine: Three Windows on the Multifaceted World of Asthma in Adolescents

Asthma is a heterogeneous disease usually characterized by chronic airway inflammation and recognized as the most prevalent chronic illness among children. Despite this, the knowledge as to how asthma affects adolescents is still scarce. One of the main management problems of asthmatic adolescents is the poor adherence to pharmacological and non-pharmacological treatments. The assessment of respiratory function and the impact on quality of life are still two crucial challenges in the management of asthmatic adolescents. Additionally, the COVID-19 pandemic has prompted physicians to explore complementary management strategies including telemedicine technologies. This review aims to provide an update on the contribution of respiratory functional tests, how asthma affects quality of life of adolescents and, finally, how telemedicine contributes to the management of adolescent asthmatics during the COVID-19 pandemic.

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

BACKGROUND

Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients.

METHODS

Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates.

RESULTS

47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03-1.10); I² = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28-1.47); I² = 14; p = 0.33]; obesity [RR = 1.30 (1.12-1.50); I² = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17-1.40); I² = 0; p = 0.62]; higher income [RR = 1.63 (1.05-2.56); I² = 0; p = 0.52]; being employed [RR = 0.87 (0.83-0.90); I² = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79-0.84); I² = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate.

CONCLUSIONS

Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.

Psychometric properties of two instruments measuring self-efficacy and outcome expectations of providing inhaler technique education to patients

INTRODUCTION

Both the National Heart, Lung, and Blood Institute (NHLBI) and Global Initiative for Asthma (GINA) asthma practice guidelines recommend that providers routinely check inhaler technique and correct any mistakes that patients may make when using these devices. Providers, however, rarely check inhaler technique during asthma visits. The objectives of this study were to: (1) describe the development of an instrument to measure self-efficacy and outcome expectations regarding inhaler technique patient education, (2) evaluate the internal consistency reliability of the new scales, and (3) provide preliminary evidence of construct validity. Methods: First- and second-year physician assistant (PA) students at two institutions completed an anonymous and voluntary survey evaluating two new instruments, the Teaching Inhalers to Patients: Self-efficacy (TIP-SE) and the Teaching Inhalers to Patients: Outcome Expectations (TIP-OE) scales and sociodemographic characteristics. The data were analyzed using Principal Components Analysis (PCA), Cronbach's α, and multivariable logistic regression. Results: We had usable responses from 146 PA students (71.9% participation rate). The PCA identified one factor for the TIP-SE and TIP-OE, respectively. The internal consistency of the TIP-SE and TIP-OE was α = 0.96 and α = 0.92, respectively. The logistic regression found that second-year PA students who had higher mean TIP-SE scores were significantly more likely to report teaching patients to use inhalers during rotations (OR = 1.8, 95% CI = 1.1, 2.9). There was not a statistically significant relationship between reporting teaching patients to use inhalers during rotations and mean TIP-OE scores. Conclusion: The TIP-SE and TIP-OE show preliminary evidence of reliability and validity.

Supplemental data for this article is available online at https://doi.org/10.1080/02770903.2021.2008428 .

Psychosocial factors and lack of asthma knowledge undermine child and adolescent adherence to inhaled corticosteroid

This study aimed to evaluate inhaled corticosteroid (ICS) adherence and identify factors associated with non-adherence in pediatric asthma patients. A total of 134 patients aged 8-18 years old were included. At the first visit, patient adherence, asthma knowledge, and outcome expectation data were collected and recorded. Depression, anxiety, and self-esteem were assessed using psychiatric questionnaires. After providing asthma education, reevaluation of adherence and asthma control was performed at one 3- to 6-month follow-up visit. The mean ICS adherence was 75.9 ± 27.5%. Fifty-seven patients (42.5%) were defined as having poor adherence (<75%). "Intentional" and "hectic lifestyle and forgetfulness" were the main reasons for missing ICS doses in mid-late adolescents and children, respectively. Asthma knowledge generally improved with age. Overall, 89% and 67.7% of patients could define symptoms and triggers of asthma, respectively; however, less than 25% understood how asthma affected their body and the chronic nature of asthma. Patients with ICS adherence <75% had unfavorable expectations from asthma treatment (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.10), and a higher proportion of inhaled short-acting beta-agonist use before exercise (OR: 4.12, 95% CI: 1.27-13.36). Depression and anxiety were frequently found (27.5%) and 23.3%, respectively; p > 0.05). Significant improvement in ICS adherence (p = 0.02) and Asthma Control Test scores (p = 0.02) were observed at the follow-up visit. Patient outcome expectations could be predictors of ICS adherence. Patient education regarding the mechanism and nature of asthma should be considered as an intervention for improving pediatric patient adherence. Psychological evaluation is warranted in pediatric patients with asthma.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

Impact of a pharmaceutical care incentive program on the asthma medication ratio among pediatric patients with persistent asthma enrolled in a Medicaid program

BACKGROUND: Asthma is one of the leading chronic disease states in pediatric patients in Texas. Pharmacy-led interventions such as targeted asthma education, scheduled consultations, and monitoring have shown success in improving asthma outcomes. However, no studies have evaluated the impact of the pharmaceutical care incentive (PCI) programs on Texas Medicaid pediatric beneficiaries. OBJECTIVES: To (1) describe the prevalence of asthma medication utilization and persistent asthma among Medicaid pediatric patients in Texas Health Service Region 11 (HSR 11) and (2) describe the prevalence and impact of PCI program interventions offered by pharmacists to Medicaid pediatric patients or their caregivers at the point-of-service in their medication utilization and asthma medication ratio (AMR). METHODS: This study used a 2-year longitudinal assessment of Medicaid pharmacy claims for beneficiaries aged between 0 and 18 years, with continuous enrollment, and at least 1 asthma medication claim during 2018 and 2019. The prevalence of asthma medication utilization during the study period was described. Also, the prevalence of PCI interventions among beneficiaries with at least 1 asthma medication was described. The prevalence of PCI interventions was also estimated for beneficiaries with persistent asthma. The AMR for beneficiaries with persistent asthma was calculated and compared for those with and without at least 1 PCI intervention. RESULTS: 22,051 beneficiaries with continuous enrollment between the ages of 0 and 18 years and with at least 1 pharmacy claim for an asthma medication during the study period were included. The overall prevalence of asthma medication utilization was 14.55%. 374 (1.70%) beneficiaries with at least 1 asthma medication received at least 1 asthma PCI intervention. Among beneficiaries that received at least 1 asthma PCI intervention, 158 (42.25%) were on rescue medication only; 4 (1.07%) were on maintenance medication only; and 212 (56.68%) were on rescue and maintenance medications. The overall prevalence of persistent asthma was 4.86%. 52 (0.76%) persistent asthma cases received at least 1 asthma PCI intervention after the index date. The overall unadjusted mean AMR (SD) for the 6,885 beneficiaries with persistent asthma was 0.50 (0.19). The adjusted AMR (SD) among beneficiaries with persistent asthma was reported at 0.530 (0.026) for beneficiaries who received at least 1 PCI intervention and 0.483 (0.002) for beneficiaries who did not receive a PCI intervention (P = 0.066). Beneficiaries with persistent asthma generated 64.35% of the total asthma pharmacy claims during 2019. CONCLUSIONS: Despite a high utilization of asthma medications among Medicaid pediatric beneficiaries, pharmacists servicing this group are underusing the PCI program interventions. An increase in the AMR among patients with persistent asthma receiving PCI interventions was observed when compared with those without PCI interventions. However, the difference was not statistically significant. Subsequent studies should include larger groups of beneficiaries receiving PCI interventions to establish the effect of PCI interventions on AMR before widespread implementation. DISCLOSURES: This research project was supported by the Global Institute for Hispanic Health (GIHH) through research grant M1803961. The authors have nothing to disclose. A part of this study was presented as a poster at the AMCP 2020 Virtual Annual Meeting and Exposition Meeting, April 21-24, 2020.

How I Do It: Transitioning Asthma Care From Adolescents to Adults

Children with asthma grow to become adults with asthma. Adolescents are not simply older children and do not automatically transform into independent adults, nor do they become proficient in self-management of their condition overnight. Adolescence is a high-risk time for many people with asthma, with increased risk of asthma-related morbidity and mortality. Children with high-risk asthma attend hospital-based asthma clinics with their parents until they reach young adulthood, and parents usually take on the significant burden of disease management on behalf of their children. Once patients are transferred to adult medical teams, many will continue to have limited knowledge about their asthma, limited understanding of how to manage their symptoms and comorbidities, and limited comprehension of how and why to take their regular medication. Adolescence is a critical time of change during which young people yearn for autonomy. Effective transition gives young people the skills and knowledge necessary to manage their health independently and provides the substrate for autonomous care, the bed rock of long-term conditions. This review focuses on the challenges of adolescent health care and provides guidance on how to take a planned, patient-centered approach to ensure each transition is effective and safe.

Influence of social support on asthma self-management in adolescents

OBJECTIVE

Adolescents with asthma are influenced by peers and family. The objective was to better understand family social support and test its association with medication adherence, asthma control, and Emergency Department (ED) use.

METHODS

This study is a cross-sectional secondary data analysis from a randomized controlled trial with urban adolescents from three U.S. cities. Participants (12-20 years old) with asthma completed the Perceived Family Support Scale (PFS) and Horne's Medication Adherence Report Scale (MARS). Data from both tools were classified into 2 categories- high and low (< 25th percentile) perceived family support and high (total score >10) and low medication adherence, respectively. Chi-square statistic and logistic regression were used for analysis.

RESULTS

Of the 371 participants, the majority were young (96% ≤ 17 years), African American or Bi-racial (85%), and Medicaid-insured (72%); over one-third had maternal family history of asthma. Among those on a controller medication (n = 270), only 37% reported its use ≥8 days over 2 weeks. Asthma control was poor with 50% categorized "not well controlled," 34% "very poorly controlled." Participants responded positively to most social support items. One item, providing and receiving social support to and from family members, was less often positively reported. Low medication adherence was significantly associated with lower perceived social support (p = 0.018).

CONCLUSION

This study underscores the importance of family social support in understanding the extent of adolescents' self-management, particularly medication adherence.

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.

Treatment Adherence in Adolescents with Asthma

The burden of asthma is particularly notable in adolescents, and is associated with higher rates of prevalence and mortality compared with younger children. One factor contributing to inadequate asthma control in adolescents is poor treatment adherence, with many pediatric studies reporting mean adherence rates of 50% or lower. Identifying the reasons for poor disease control and adherence is essential in order to help improve patient quality of life. In this review, we explore the driving factors behind non-adherence in adolescents with asthma, consider their consequences and suggest possible solutions to ensure better disease control. We examine the impact of appropriate inhaler choice and good inhaler technique on adherence, as well as discuss the importance of selecting the right medication, including the possible role of as-needed inhaled corticosteroids/long-acting β₂-agonists vs short-acting β₂-agonists, for improving outcomes in patients with mild asthma and poor adherence. Effective patient/healthcare practitioner communication also has a significant role to engage and motivate adolescents to take their medication regularly.

Effect of an Asthma Question Prompt List and Video Intervention on Adolescents' Medication Adherence 12 Months Later

BACKGROUND

Many adolescents do not obtain the maximum benefit from their asthma medications. Improving patient-provider communication may improve adolescents' asthma knowledge, adherence, and clinical outcomes.

OBJECTIVE

To determine how a question prompt list and educational video intervention affect youth- and caregiver-reported medication adherence and self-reported medication problems.

METHODS

Adolescents with persistent asthma (n = 359; 56.4% with moderate to severe asthma) and their caregivers were enrolled in a randomized controlled trial at 4 pediatric clinics. Intervention group families received a question prompt list and watched a short video before seeing the provider; control families received usual care. Youth- and caregiver-reported medication adherence was measured with a Visual Analog Scale, ranging from 0 to 100. Generalized estimating equations were used to determine how the intervention and covariates were associated with medication adherence and reported problems at 12 months.

RESULTS

The intervention was not a significant predictor of medication adherence at 12 months. Higher caregiver education was associated with higher youth-reported adherence (β = 1.1; 95% CI = 0.1, 2.1; P = 0.036) and caregiver-reported adherence (β = 1.2; 95% CI = 0.3, 2.0; P = 0.006). The intervention was associated with fewer caregiver-reported problems at 12 months (β = -0.32; 95% CI = -0.48, -0.16; P < 0.001).

CONCLUSIONS AND RELEVANCE

A question prompt list and educational video decreased the number of caregiver-reported medication problems, but did not significantly affect medication adherence. Further research is needed to develop more effective interventions to improve medication adherence and outcomes.