A pragmatic behavior-based habit index for adherence to nebulized treatments among adults with cystic fibrosis

Adherence to 6-Mercaptopurine (6-MP) and Habit Strength in Pediatric Acute Lymphoblastic Leukemia (ALL)

BACKGROUND

Low 6-mercaptopurine (6-MP) adherence (< 95%) is associated with increased relapse in pediatric acute lymphoblastic leukemia (ALL). Stronger habit has been associated with higher adherence. We examined the relationship of 6-MP adherence to habit strength and health-related quality of life in pediatric ALL.

METHODS

A single-center, cross-sectional study of 52 participants: 11 patients (mean age 16 ± 4) and 41 parents/caregivers (age 37 ± 5). Participants completed Visual Analogue Scale (VASdose), Patient Reported Outcomes Measurement Information System Medication Adherence Scale, and the Self-Regulated Habit Index (SRHI). Twelve semi-structured participant interviews were analyzed using thematic analysis.

RESULTS

81% (42/52) of participants reported high 6-MP adherence (VASdose ≥ 95%): patients 91% (10/11), parents 78% (32/41). No significant correlation was found between adherence and habit strength. Reported adherence facilitators included reminders, care team communications, personalized tools, administration experience, self-efficacy, and social support. Conversely, financial burden, scheduling conflicts, and medication access were cited as barriers.

CONCLUSIONS

One-fifth of participants reported low 6-MP adherence, with habit strength not associated with adherence. Variability of 6-MP routines may prohibit automaticity. While 6-MP adherence may not correlate with habit strength, interventions promoting and strengthening habit formation may overcome barriers to 6-MP adherence and improve outcomes.

Correlation Between Objective Habit Metrics and Objective Medication Adherence: Retrospective Study of 15,818 Participants From Clinical Studies

BACKGROUND

Medication adherence, or how patients take their medication as prescribed, is suboptimal worldwide. Improving medication-taking habit might be an effective way to improve medication adherence. However, habit is difficult to quantify, and conventional habit metrics are self-reported, with recognized limitations. Recently, several objective habit metrics have been proposed, based on objective medication-taking data.

OBJECTIVE

We aim to explore the correlation between objective habit metrics and objective medication adherence on a large dataset.

METHODS

The Medication Event Monitoring System Adherence Knowledge Center, a database of anonymized electronic medication intake data from ambulant participants enrolled in past clinical studies, was used as the data source. Electronic medication intake data from participants following a once-daily regimen and monitored for 14 days or more were used. Further, two objective habit metrics were computed from each participant's medication intake history: (1) SD of the hour of intake, representing daily variability in the timing of medication intakes, and (2) weekly cross-correlation, representing weekly consistency in the timing of medication intakes. The implementation component of medication adherence was quantified using (1) the proportion of doses taken and (2) the proportion of correct days.

RESULTS

A total of 15,818 participants met the criteria. These participants took part in 108 clinical studies mainly focused on treatments for hypertension (n=4737, 30%) and osteoporosis (n=3353, 21%). The SD of the hour of intake was significantly negatively correlated with the 2 objective adherence metrics: proportion of correct days (Spearman correlation coefficient, ρS=-0.62, P<.001) and proportion of doses taken (ρS=-0.09, P<.001). The weekly cross-correlation was significantly positively correlated with the 2 objective adherence metrics: proportion of correct days (ρS=0.55, P<.001) and proportion of doses taken (ρS=0.32, P<.001). A lower daily or weekly variability in the timing of medication intakes is thus associated with better medication adherence. However, no variability is not the norm, as only 3.6% of participants have 95% of their intakes in a 1-hour window. Among the numerous factors influencing medication adherence, habit strength is an important one as it explains over 30% of the variance in medication adherence.

CONCLUSIONS

Objective habit metrics are correlated to objective medication adherence. Such objective habit metrics can be used to monitor patients and identify those who may benefit from habit-building support.

Evaluating Objective Metrics of habit strength for taking medications

Habit strength for taking medication is associated with medication adherence. However, habit strength is typically measured via self-reports, which have limitations. Objective sensors may provide advantages to self-reports. To evaluate whether habit-strength metrics derived from objective sensor data (MEMS® Caps; AARDEX Group) are associated with self-reported habit strength and adherence (objective and self-reported) and whether objective and self-reported habit strength are independently associated with adherence. Patients (N = 79) on oral medications for type 2 diabetes completed self-reports of habit strength and medication adherence and used MEMS® Caps to take their prescribed medication for one month. MEMS® Caps data were used to create five objective metrics of habit strength (e.g., individual-level variance in pill timing) and quantify medication adherence (% days correct dosing). Consistency in behavior from week to week (versus across each day) had the greatest association with self-reported habit strength (r(78) = 0.29, p = 0.01), self-reported adherence (r(78) = 0.32, p = 0.005), and objective adherence (r(78) = 0.61, p < 0.001). Objective and self-reported habit strength were independently associated with adherence. Weekly pill-timing consistency may be more useful than daily pill-timing consistency for predicting adherence and understanding patients' medication-taking habits. Self-reports and objective metrics of habit strength may be measuring different constructs, warranting further research.

Developing ciprofloxacin dry powder for inhalation: A story of challenges and rational design in the treatment of cystic fibrosis lung infection

Cystic fibrosis (CF) is an inherited multisystem disease affecting the lung which leads to a progressive decline in lung function as a result of malfunctioning mucociliary clearance and subsequent chronic bacterial infections. Pseudomonas aeruginosa is the predominant cause of lung infection in CF patients and is associated with significant morbidity and mortality. Thus, antibiotic therapy remains the cornerstone of the treatment of CF. Pulmonary delivery of antibiotics for lung infections significantly reduces the required dose and the associated systemic side effects while improving therapeutic outcomes. Ciprofloxacin is one of the most widely used antibiotics against P. aeruginosa and the most effective fluoroquinolone. However, in spite of the substantial amount of research aimed at developing ciprofloxacin powder for inhalation, none of these formulations has been commercialized. Here, we present an integrated view of the diverse challenges associated with delivering ciprofloxacin dry particles to the lungs of CF patients and the rationales behind recent formulations of ciprofloxacin dry powder for inhalation. This review will discuss the challenges in developing ciprofloxacin powder for inhalation along with the physiological and pathophysiological challenges such as ciprofloxacin lung permeability, overproduction of viscous mucus and bacterial biofilms. The review will also discuss the current and emerging particle engineering approaches to overcoming these challenges. By doing so, we believe the review will help the reader to understand the current limitations in developing an inhalable ciprofloxacin powder and explore new opportunities of rational design strategies.

Time-of-Day Differences in Treatment-Related Habit Strength and Adherence

Background

Many of our daily behaviors are habitual, occurring automatically in response to learned contextual cues, and with minimal need for cognitive and self-regulatory resources. Behavioral habit strength predicts adherence to actions, including to medications. The time of day (morning vs. evening) may influence adherence and habit strength to the degree that stability of contexts/routines varies throughout the day.

Purpose

The current study evaluates whether patients are more adherent to morning versus evening doses of medication and if morning doses show evidence of greater habit strength than evening doses.

Methods

Objective adherence data (exact timing of pill dosing) were collected in an observational study by electronic monitoring pill bottles in a sample of patients on twice-daily pills for Type 2 diabetes (N = 51) over the course of 1 month.

Results

Data supported the hypothesis that patients would miss fewer morning than evening pills. However, counter to the hypothesis, variability in dose timing (an indicator of habit strength) was not significantly different for morning versus evening pills.

Conclusions

Findings suggest that medication adherence may be greater in the morning than in the evening. However, more research is needed to evaluate the role of habitual action in this greater adherence. Furthermore, future research should evaluate the validity of behavioral timing consistency as an indicator of habit strength.

Habit Strength, Medication Adherence, and Habit-Based Mobile Health Interventions Across Chronic Medical Conditions: Systematic Review

BACKGROUND

Unintentional medication nonadherence is common and has been associated with poor health outcomes and increased health care costs. Earlier research demonstrated a relationship between habit strength and medication adherence. Previous research also examined a habit's direct effect on adherence and how habit interacts with more conscious factors to influence or overrule them. However, the relationship between habit and adherence and the role of habit-based mobile health (mHealth) interventions remain unclear.

OBJECTIVE

This review aimed to systematically evaluate the most recent evidence for habit strength, medication adherence, and habit-based mHealth interventions across chronic medical conditions.

METHODS

A keyword search with combinations of the terms habit, habit strength, habit index, medication adherence, and medication compliance was conducted on the PubMed database. After duplicates were removed, two authors conducted independent abstract and full-text screening. The guidelines for the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed when reporting evidence across the included and reviewed studies.

RESULTS

Of the 687 records examined, 11 met the predefined inclusion criteria and were finalized for data extraction, grading, and synthesis. Most included studies (6/11, 55%) were cross-sectional and used a theoretical model (8/11, 73%). The majority of studies measured habit strength using the self-report habit index and self-report behavioral automaticity index (9/11, 82%). Habit strength was positively correlated with medication adherence in most studies (10/11, 91%). Habit mediated the effects of self-efficacy on medication adherence (1/11, 9%), and social norms moderated the effects of habit strength on medication adherence (1/11, 9%). Habit strength also moderated the effects of poor mental health symptoms and medication adherence (1/11, 9%). None of the included studies reported on using or proposing a habit-based mHealth behavioral intervention to promote medication adherence.

CONCLUSIONS

Habit strength was strongly correlated with medication adherence, and stronger habit was associated with higher medication adherence rates, regardless of the theoretical model and/or guiding framework. Habit-based interventions should be used to increase medication adherence, and these interventions could leverage widely available mobile technology tools such as mobile apps or text messaging, and existing routines.