Adherence-related behavior in adolescents with asthma: results from focus group interviews

Validation of an app-based portable spirometer in adolescents with asthma

OBJECTIVES

Objective measurements of asthma impairment could aid teens in recognition of changes in asthma status over time. Ready access to a conventional spirometer is not realistic outside of the clinical setting. In this proof-of-concept study, we compared the performance of the VitalFlo mobile spirometer to the nSpire KoKo® sx1000 spirometer for accuracy in measuring Forced Expiratory Volume in one second (FEV₁) and Forced Vital Capacity (FVC) in adolescents with asthma.

METHODS

Two hundred forty pulmonary function measurements were collected from 48 adolescents with persistent asthma from the University of North Carolina's pediatric allergy and pulmonology subspecialty clinics. Participants performed spirometry with the nSpireKoKo® sx1000 spirometer and the VitalFlo spirometer during their clinic visits. 119 simulated FVC maneuvers were conducted on both devices to standardize measurements. Pearson correlations, Bland-Altman procedure, and two-sample comparison tests were performed to assess the relationship between the two spirometers.

RESULTS

VitalFlo measurements were significantly highly correlated with nSpireKoKo® spirometer values for FEV_1, (r²=0.721, [95% CI, 0.749 ± 0.120], P < 0.001) and moderately for FVC (r²= 0.617, [95% CI, 0.640 ± 0.130], P < 0.001) measurements. There were no statistically significant differences of the mean FEV₁ (M = 0.00764, SD = 0.364, t(59)=0.16, P = 0.87) and FVC measurements (M = 0.00261, SD = 0.565, t(59)=0.036, P = 0.97.) between the VitalFlo and nSpireKoKo® systems. Both devices demonstrated significantly high correlation when comparing the automated FVC (r² = 0.997, [95% CI, 1.00 ± 0.00974], P < 0.001) measurements. Bland-Altman plots did not demonstrate significant bias between devices for both FEV₁ (0.00764 L) and FVC (0.00261 L) measurements.

CONCLUSIONS

Lung function measurements from the VitalFlo mobile spirometer were comparable to a commercially-available spirometer commonly used in clinical settings. This validated app-based spirometer for home use has the potential to improve asthma self-management.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Barriers and facilitators to asthma self-management in adolescents: A systematic review of qualitative and quantitative studies

BACKGROUND

Many adolescents have poor asthma control and impaired quality of life despite the availability of modern pharmacotherapy. Research suggests that poor adherence to treatment and limited engagement in self-management could be contributing factors.

OBJECTIVE

To conduct a systematic review of the barriers and facilitators to self-management of asthma reported by adolescents using a narrative synthesis approach to integrate the findings.

DESIGN

MEDLINE, EMBASE, CINAHL, and PsycINFO were searched for all types of study design. Full papers were retrieved for study abstracts that included data from participants aged 12-18 years referring to barriers or facilitators of asthma self-management behaviors.

RESULTS

Sixteen studies (5 quantitative and 11 qualitative) underwent data extraction, quality appraisal, and thematic analysis. Six key themes were generated that encompassed barriers and/or facilitators to self-management of asthma in adolescents: Knowledge, Lifestyle, Beliefs and Attitudes, Relationships, Intrapersonal Characteristics, and Communication.

CONCLUSIONS

There is a pressing need to prepare adolescents for self-management, using age-appropriate strategies that draw on the evidence we have synthesized. Current clinical practice should focus on ensuring adolescents have the correct knowledge, beliefs, and positive attitude to self-manage their illness. This needs to be delivered in a supportive environment that facilitates two-way communication, fosters adolescents' self-efficacy to manage their disease, and considers the wider social influences that impinge on self-management. Pediatr Pulmonol. 2017;52:430-442. © 2016 Wiley Periodicals, Inc.

Reliability and predictors of resistive load detection in children with persistent asthma: a multivariate approach

OBJECTIVE

Resistive load detection tasks enable analysis of individual differences in psychophysical outcomes. The purpose of this study was to determine both the reliability and predictors of resistive load detection in children with persistent asthma who completed multiple testing sessions.

METHODS

Both University of North Carolina (UNC) Charlotte and Ohio University institutional review boards approved the research protocol. The detection of inspiratory resistive loads was evaluated in 75 children with asthma between 8 and 15 years of age. Each child participated in four experimental sessions that occurred approximately once every 2 weeks. Multivariate analyses were used to delineate predictors of task performance.

RESULTS

Reliability of resistive load detection was determined for each child, and predictors of load detection outcomes were investigated in two groups of children: those who performed reliably in all four sessions (n = 31) and those who performed reliably in three or fewer sessions (n = 44). Three factors (development, symptoms, and compliance) accounted for 66.3% of the variance among variables that predicted 38.7% of the variance in load detection outcomes (Multiple R = 0.62, p = 0.004) and correctly classified performance as reliable or less reliable in 80.6% of the children, χ(2)(12) = 28.88, p = 0.004.

CONCLUSIONS

Cognitive and physical development, appraisal of symptom experiences, and adherence-related behaviors (1) account for a significant proportion of the interrelationships among variables that affect perception of airflow obstruction in children with asthma and (2) differentiate between children who perform more or less reliably in a resistive load detection task.

Asthma medication adherence among urban teens: a qualitative analysis of barriers, facilitators and experiences with school-based care

OBJECTIVE

Teens with persistent asthma do not always receive daily preventive medications or do not take them as prescribed, despite established clinical guidelines. The purpose of this study was to understand urban teens' experiences with asthma management, preventive medication adherence and participation in a school-based intervention.

METHODS

Teens (12-15 years) with persistent asthma, and prescribed preventive medication, participated in a pilot study that included daily observed medication therapy at school and motivational interviewing. Semi-structured interviews occurred at final survey. Qualitative content analysis enabled data coding to identify themes.

RESULTS

Themes were classified as "general asthma management" or "program-specific." For general management, routines were important, while hurrying interfered with taking medications. Forgetfulness was most commonly linked to medication nonadherence. Competing demands related to school preparedness and social priorities were barriers to medication use. Independence with medications was associated with several benefits (e.g. avoiding parental nagging and feeling responsible/mature). Program-specific experiences varied. Half of teens reported positive rapport with their school nurse, while a few felt that their nurse was dismissive. Unexpected benefits and barriers within the school structure included perceptions about leaving the classroom, the distance to the nurse's office, the necessity of hall passes and morning school routines. Importantly, many teens connected daily medication use with fewer asthma symptoms, incenting continued adherence.

CONCLUSIONS

Teens with asthma benefit from adherence to preventive medications but encounter numerous barriers to proper use. Interventions to improve adherence must accommodate school demands and unique teen priorities. The school nurse's role as an ally may support teens' transition to medication independence.

Adolescent decision-making about use of inhaled asthma controller medication: results from focus groups with participants from a prior longitudinal study

BACKGROUND

Adherence with inhaled controller medications for asthma is known to be highly variable with many patients taking fewer doses than recommended for consistent control of lung inflammation. Adherence also worsens as children become teenagers, although the exact causes are not well established.

OBJECTIVE

To use focus group methodology to examine beliefs, feelings, and behaviors about inhaled asthma controller medication in adolescents and young adults who had previously participated in a longitudinal study of asthma treatment adherence and outcome in order to develop more effective management strategies.

METHODS

Twenty-six subjects participated in 6 focus groups comprised of 3-5 young adults (age range 12-20 years). Verbatim transcripts of these groups were analyzed using the long-table method of content analysis to identify key themes raised by participants.

RESULTS

A variety of beliefs, feelings, and behaviors influence the adolescent's decision about how to use their asthma medication. Some of the adolescents understood the importance of daily medication and were committed to the treatment plan prescribed by their provider. Poorer adherence was the product of misinformation, incorrect assumptions about their asthma, and current life situations.

CONCLUSIONS

These results, by highlighting potential mechanisms underlying both better and worse adherence, inform the development of strategies to improve adherence behavior in adolescents and young adults with asthma. Knowledge of the specific beliefs, feelings, and behaviors that underlie adolescents' use of inhaled asthma controller medication will help providers maximize treatment adherence in this notoriously difficult patient population.

Adolescents' commitment to continuing psychotropic medication: a preliminary investigation of considerations, contradictions, and correlates

This mixed-method study examines (1) the extent to which fifty adolescents receiving wraparound treatment and prescribed psychotropic medication for various psychiatric disorders report that they would continue taking medication if the decision was entirely their own (termed "medication commitment"); (2) their general subjective experiences with medication; and (3) which medication experiences and clinical, social, and demographic factors are associated with greater medication commitment. We found that most adolescents (62%) would discontinue treatment; these "less committed" youth were more likely to report various negative medication perceptions and experiences in open-ended questions, relative to "committed" youth. Multivariate analysis indicated that significant correlates of commitment to medication were: taking antipsychotic medication, greater perceived family support, and lack of perceived coercion to take the medication; clinical or demographic factors were not significantly related to medication commitment. The results reinforce the importance of addressing youths' concerns about medication and maximizing their participation in treatment decision-making.

Medication use patterns among urban youth participating in school-based asthma education

Although pharmaceutical management is an integral part of asthma control, few community-based analyses have focused on this aspect of disease management. The primary goal of this analysis was to assess whether participation in the school-based Kickin' Asthma program improved appropriate asthma medication use among middle school students. A secondary goal was to determine whether improvements in medication use were associated with subsequent improvements in asthma-related symptoms among participating students. Students completed an in-class case-identification questionnaire to determine asthma status. Eligible students were invited to enroll in a school-based asthma curriculum delivered over four sessions by an asthma health educator. Students completed a pre-survey and a 3-month follow-up post-survey that compared symptom frequency and medication use. From 2004 to 2007, 579 participating students completed pre- and post-surveys. Program participation resulted in improvements in appropriate use across all three medication use categories: 20.0% of students initiated appropriate reliever use when "feeling symptoms" (p < 0.001), 41.6% of students reporting inappropriate medication use "before exercise" initiated reliever use (p < 0.001), and 26.5% of students reporting inappropriate medication use when "feeling fine" initiated controller use (p < 0.02). More than half (61.6%) of participants reported fewer symptoms at post-survey. Symptom reduction was not positively associated with improvements in medication use in unadjusted and adjusted analysis, controlling for sex, asthma symptom classification, class attendance, season, and length of follow-up. Participation in a school-based asthma education program significantly improved reliever medication use for symptom relief and prior-to-exercise and controller medication use for maintenance. However, given that symptom reduction was not positively associated with improvement in medication use, pharmaceutical education must be just one part of a comprehensive asthma management agenda that addresses the multifactorial nature of asthma-related morbidity.

Adolescents and asthma: why bother with our meds?

BACKGROUND

Adherence to inhaled steroid regimens for asthma is poor in adults and children. Although it is assumed that nonadherence contributes to morbidity in older adolescents, investigation is limited.

OBJECTIVE

We sought to describe adherence to preventive asthma medications and explore relevant beliefs and attitudes in older urban adolescents, including their ideas for improving adherence.

METHODS

Quantitative and qualitative methods were used to collect data from a convenience sample of adolescents with asthma previously prescribed fluticasone/salmeterol (F/S). Two semistructured face-to-face interviews were conducted 1 month apart and analyzed for themes. F/S use was electronically monitored between visits and calculated as the number of actuations divided by the number of inhalations prescribed.

RESULTS

Forty participants, (15-18 years of age, 19 female subjects, 30 black/African American subjects, 11 Medicaid-insured subjects, and 24 previously hospitalized for asthma) with a median FEV1 of 98% of predicted value (range, 67% to 127%) had median adherence of 43% (range, 4% to 89%). Adherence was not associated with FEV1 or emergency department visits. Themes emerged from interviews as follows. Teens (1) take F/S inconsistently; (2) believe F/S is "supposed to help me breathe"; (3) dislike its taste; (4) are "too busy" and "forget"; and (5) recommend "reminder" solutions to poor adherence. Twenty percent believed that taking F/S was unnecessary, and another 18% expressed ambivalence about its benefits.

CONCLUSION

Adherence was poor. Examining and acknowledging health beliefs of older teens in the context of their complicated lives might facilitate discussions about self-management.

Adolescent experience of psychotropic treatment

Despite growing concern over the treatment of adolescents with psychiatric medications, little research has examined youth understandings and interpretations of mental illness and psychotropic treatment. This article reports the exploratory findings of semi-structured and open-ended interviews carried out with 20 adolescents diagnosed with one or more psychiatric disorders, and who were currently prescribed psychiatric medications. Grounded theory coding procedures were used to identify themes related to adolescent subjective experience with psychiatric medications. The categories identified are interpreted as different points of view through which adolescents understand and take action upon their illness concerns; their need for medication treatment; their perceptions of how medications work; their responses to parental and other influences upon medication treatment; and, their everyday management activities.

Factors associated with asthma management self-efficacy among 7th and 8th grade students

OBJECTIVE

Examine correlates of asthma self-management among 12,154 adolescents with physician-diagnosed asthma.

METHODS

All 7th and 8th grade students in North Carolina completed a survey to assess asthma prevalence and self-management behaviors among those with asthma.

RESULTS

Adolescents who were allowed to carry their inhaled medication at school, shown how to use a peak flow meter, and had access to more asthma care resources were more confident that they could prevent an asthma exacerbation. Adolescents who were allowed to carry their inhaled medication at school and who had a private doctor were more confident that they could control their symptoms. Adolescents taking anti-inflammatory medicine were less confident that they could prevent an exacerbation and control their symptoms.

CONCLUSIONS

Various indicators of autonomy and control were associated with greater self-efficacy for managing asthma. Adolescents who require anti-inflammatory medicines would benefit from additional intervention efforts to improve their asthma management self-efficacy.

Asthma beliefs among mothers and children from different ethnic origins living in Amsterdam, the Netherlands

Background

Doctors and patients hold varying beliefs concerning illness and treatment. Patients' and families' explanatory models (EMs) vary according to personality and sociocultural factors. In a multi-ethnic society, it is becoming increasingly significant that doctors understand the different beliefs of their patients in order to improve patient/doctor communication as well as patient adherence to treatment.

Methods

Twelve focus groups were formed, consisting of 40 children diagnosed with asthma, as well as 28 mothers of these children. These groups included mothers and children of different ethnicities who were living in Amsterdam, the Netherlands. In order to understand the beliefs that both mothers and children hold regarding asthma and its treatment, the explanatory models were analysed and compared.

Results

Study findings show that mothers and children, regardless of ethnicity and age, have their own EMs. Overall, there is a great deal of uncertainty related to the causes, consequences, problems, and symptoms of asthma and its treatment. It also seems that many concerns and feelings of discomfort are the result of lack of knowledge. For instance, the fact that asthma is not seen as a chronic disease requiring daily intake of an inhaled corticosteroid, but rather as an acute phenomenon triggered by various factors, may be very relevant for clinical practice. This particular belief might suggest an explanation for non-adherent behaviour.

Conclusion

A thorough understanding of the mothers' and children's beliefs regarding the illness and its treatment is an important aspect in the management of asthma. Gaining an understanding of these beliefs will provide a foundation for a solid clinician-patient/family partnership in asthma care. Although ethnic differences were observed, the similarities between the mothers' and children's beliefs in this multi-ethnic population were striking. In particular, a common belief is that asthma is considered an acute rather than a chronic condition. In addition, there is a lack of knowledge about the course and the self-management of asthma. Health care providers should be aware of these commonly held beliefs, and this information could be shared in educational programs.

Asthma worsenings: approaches to prevention and management from the Asthma Worsenings Working Group

Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or night-time symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods.To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary care physicians, pharmacists and specialists is likely to have the greatest impact on the identification, prevention and management of asthma worsenings.

Features of asthma management: quantifying the patient perspective

BACKGROUND

In the management of asthma, features of care important to patients may not be fully appreciated. This study quantifies the importance of different features of asthma management from the patient perspective. This may assist in the development of personalised management strategies.

METHODS

We used the technique of discrete choice experiment (DCE). Patients over 18 years of age with asthma, prescribed and taking medicine at step 3 of the UK guidelines were recruited from 15 general (family) practices in three areas of the UK. 147 evaluable questionnaires were returned from a total of 348 sent out. The outcome measures were the relative importance to patients of features of asthma management and the impact of changes in asthma management, as measured by utility shift between the features tested.

RESULTS

The largest shift in mean utility values was recorded in "number of inhalers" and "use of inhaled steroid". Use of a personal asthma action plan was ranked next highest.

CONCLUSION

This study suggests that adults with moderate or severe asthma would trade some improvements in symptom relief in favour of, for example, simpler treatment regimens that use as few inhalers as possible and a lower dose of inhaled steroid.

Predictors of good adherence of adolescents with diabetes (insulin-dependent diabetes mellitus)

OBJECTIVES

The purpose of this study was to identify the factors that predict good adherence to health regimens by adolescents with diabetes (insulin-dependent diabetes mellitus).

METHODS

Altogether, 300 individuals aged 13-17 years were randomly selected from the Finnish Social Insurance Institution's register. Ninety-seven per cent (N=289) of the selected adolescents returned the questionnaire. The data were analysed using the SPSS (Statistical Package for Social Sciences) for Windows software package. Logistic regression was used to find the factors that predict good adherence to health regimens.

RESULTS

About one-fifth (19%) of the respondents with diabetes felt that they complied fully with the health regimens, while 75% placed themselves in the category of satisfactory adherence, and the remaining 6% reported poor adherence. The most powerful predictor was the threat to mental wellbeing. The likelihood that adolescents who felt the disease to be a threat to their mental wellbeing would comply with health regimens was 7.68-fold as compared to those who did not regard the disease as a threat to their mental wellbeing. The next most powerful predictor was support from physician. The support from nurses, and the motivation, energy and willpower to take care of themselves and the threat to physical wellbeing, also predicted good adherence. The logistic regression model explained 82% of the variance, and the model predicted correctly 88% of the adolescents with good adherence.

DISCUSSION

This paper shows that adolescents with diabetes show quite good adherence. It also indicates the factors that predict good adherence to health regimens. To improve adherence, these factors should be given special attention in the care of adolescents.

Feeling Good in Daily Life: From the Point of View of Boys With Posterior Urethral Valves

PURPOSE

We determined what is important to feel good in daily life when living with a long-term illness that requires daily treatment routines.

MATERIALS AND METHODS

Seven boys between 6 and 16 years old who were born with posterior urethral valves narrated their experiences with daily life. They were on clean intermittent catheterization, had impaired renal function and 2 had undergone transplantation.

RESULTS

Being involved in decisions about themselves was important, as was having their own doctor and nurse. Friends were important. Clean intermittent catheterization was something that worried them in relation to friends and made them feel uncertain about how they would react to it. The boys accepted the catheterization procedure as something that had to be done but they needed strategies to be able to comply. A single event, such as no available toilet, was enough to interrupt treatment.

CONCLUSIONS

In these boys prescribed treatment was a surprisingly small part of their lives. The clean intermittent catheterization routine was sometimes experienced as an obstacle in company with friends. The new challenge might be to achieve compliance with the treatment routine in daily life in a long-term perspective.

Asthma treatment needs: a comparison of patients' and health care professionals' perceptions

BACKGROUND

Patients' perceptions of asthma tend to differ from those of clinicians, who primarily focus on asthma control. Patients' treatment needs and preferences may not be adequately addressed.

OBJECTIVE

The aims of this study were as follows: to provide data on unmet treatment needs and to investigate the main finding of a qualitative study using a questionnaire study.

METHODS

To assess treatment needs in patients with asthma, focus groups were conducted with patients/parents and clinicians. Based on these results, quantitative surveys of adult patients and parents were performed in the United Kingdom, Germany, and Spain.

RESULTS

The UK focus group comprised 11 patients and 8 parents; in Germany, there were 10 patients and 11 parents; in Spain, there were 5 patients and 8 parents. The focus groups showed some differences between clinicians' and patients'/parents' perceptions of treatment. For patients, side effects meant long-term effects (ie, 10-20 years); for clinicians, it meant occasional local problems. The quantitative study comprised 454 participants: 310 adult patients (mean [SD] age, 37.13 [13.12] years) and 142 parents (children's mean [SD] age, 13.98 [1.37] years), plus 2 nonspecified. Some patients reported good asthma control and simultaneously reported frequent exacerbations. Most patients and parents expressed a preference for a simpler regimen using fewer drugs, and most had concerns about their treatment. Although some patients concurred with treatment guidelines, 62.2% tended to rely on reliever medication (ie, bronchodilators). Additionally, 6.9% described their asthma as very well-controlled but reported experiencing asthma symptoms > or =3 days per week. Finally, 1.9% of patients and 2.1% of parents reporting very well-controlled asthma also reported visiting the emergency department or calling a physician for a home visit in the previous 3 months.

CONCLUSIONS

Asthma patients and parents of asthmatic children had unmet treatment needs and may interpret medical terminology differently than clinicians.

Patient-identified barriers to asthma treatment adherence: responses to interviews, focus groups, and questionnaires

This article reviews 32 patient-interview studies that revealed that the most common barriers to adherence revealed by patients included concerns about drug safety and cost and a belief that the patient's asthma was not severe enough to require daily treatment. Important but less commonly cited concerns included worry about dependence or diminished effectiveness with long-term use of the medication. Children and their parents expressed concerns about safety, dependence, peer stigmatization, and parent-child conflict over taking medication. Low-income and minority patients cited similar concerns and barriers that included cost, difficulty of obtaining medication, daily life hassles, and a general distrust of the medical establishment. The information obtained from patients' perspectives indicates the need to reappraise current strategies for the management of asthma, including a more flexible approach to the use of expert guidelines for the treatment of asthma.

Support network of adolescents with chronic disease: adolescents' perspective

The purpose of this study was to describe the support network of adolescents with a chronic disease from their own perspective. Data were collected by interviewing adolescents with asthma, epilepsy, juvenile rheumatoid arthritis (JRA) and insulin-dependent diabetes mellitus (IDDM). The sample consisted of 40 adolescents aged between 13 and 17 years. Interview data were examined using content analysis. Six main categories were established to describe the support network of adolescents with a chronic disease: parents, peers, school, health care providers, technology and pets. Peers were divided into two groups: fellow sufferers and peers without a chronic disease. At school, teachers, school nurses and classmates were part of the support network. Health care providers included nurses, physicians and physiotherapists. Technology was also part of the support network and included four techniques that may be used to communicate: computers, mobile telephones, television and videos. The results provided a useful insight into the social network of adolescents with chronic disease and serve to raise awareness of the problems and opinions experienced by adolescents with this condition.

Pediatric asthma: a look at adherence from the patient and family perspective

Although extensive research has been done in an effort to understand and promote adherence in pediatric asthma, little progress has been made in reducing the prevalence of nonadherence. Some researchers argue that a paradigm shift is necessary to advance the adherence field. Despite the recent trend for increasing the role of families in determining treatment plans, a patient-centered approach has been lacking in adherence to a daily regimen. It is clear that, although patients and families show evidence of inadvertent nonadherence (eg, forgetfulness), they also engage in volitional or intentional nonadherence, via reasoned and purposeful decisions. Patients conduct "experiments" with their regimen components in an effort to balance the burden of disease with the burden of treatment. These experiments typically involve some degree of nonadherence. Perhaps, if researchers strive to better understand the decision-making process involved in these experiments, health care providers can guide families in making adherence decisions that would lead to attainment of treatment goals, improvement in quality of life, and realization of positive clinical outcomes.

Why don't children take their asthma medications? A qualitative analysis of children's perspectives on adherence

Focus groups were conducted with children with asthma to generate descriptive data regarding asthma adherence. Transcripts of focus groups were analyzed using qualitative methods. Data collection occurred at an outpatient department of a university-affiliated hospital and at a summer camp for children with asthma. Thirty-six children with asthma ranging in age from 9 years, 1 month to 15 years, 3 months (M age = 11 years, 10 months) participated. Participants provided qualitative descriptions of asthma experiences, including consequences, adherence barriers, and strategies to improve adherence. Researchers also elicited participants' feedback regarding theoretically derived strategies to improve adherence. Children's perceived consequences of asthma included feeling ill, limitations on peer interactions, and medication annoyances. Frequently endorsed barriers to medication adherence were lack of motivation, difficulties remembering, and social barriers. Child-generated strategies to improve adherence included reminders, social strategies, and enhancing accessibility. When children were asked about specific strategies provided by the researchers, motivational strategies (i.e., use of reward as positive reinforcement) were the most highly endorsed. Findings revealed two paradoxes: 1) although children complained that parental reminders are annoying, they also reported that parental prompts help to improve their adherence, and 2) the use of rewards to reinforce adherence was a highly endorsed strategy when presented to children; however, children did not generate this type of strategy on their own.

Evaluation of an educational program for adolescents with asthma

In addition to challenges of adolescence itself, teens with asthma face demands of asthma management and risks of asthma sequelae, including fatalities. Few asthma educational programs specifically address their needs. In response to school nurse concern, this pilot study evaluated an adolescent asthma education program, the Power Breathing trade mark Program, together with individual coaching sessions in terms of general asthma knowledge and health status. Thirteen high school students, predominantly female and African American, participated over a 6-month period. Evaluation tools included the Child Health Survey for Asthma, a focus group interview, and a program evaluation questionnaire. Participants reported that knowledge gained improved trigger avoidance, increased medication adherence, and decreased the frequency of asthma episodes. They described the individual coaching sessions as helpful in assimilating and applying information. The Power Breathing Program and coaching sessions show promise as an asthma educational program particularly tailored to adolescents. This article suggests further evaluation of the program and describes implications for school nurses.

[Communication prostheses and behavioral alignment in hospital leaflets]

Review was made of publications that describe experience with printed material distributed to the lay public in hospital institutions. From the 146 leaflets examined, those aimed at professionals or disabled people, thus leaving 75 papers that illustrate the present pattern for the rationality behind the production, use and evaluation of this type of resource. In a general manner, such leaflets invest in the power of "ideal printed information" to align behavior with the hospital's biomedical agenda. The underlying rationality that permeates them perceives the "perfect information package" as one that efficiently describes its technical content for the purpose of unidirectional persuasion, is up-to-date in relation to readability scales and embellished by graphic design, and emphasizes the priorities defined by the professionals. Such "communication prostheses" should be capable of electronic validation by means of software suitable for proportioning the "doses" to the subject matter. Information as a drug, cognitivism, the lack of research on message reception and the need for communicative action for the deconstruction of systems of closed thinking within the hospital environment have been discussed.

Perceptions and attitudes of adolescents with asthma

BACKGROUND

Psychosocial factors can limit one's ability to effectively manage asthma. This can result in asthma morbidity that limits quality of life. While self-perceptions of asthmatic children and parents have been studied, less is known about self-perceptions of inner-city adolescents with asthma.

OBJECTIVE

To examine perceptions and attitudes to treatment among inner-city adolescents with asthma.

DESIGN/METHODS

We conducted a multistaged stratified sample survey at a high school located in the Bronx, NY. First, an asthma-screening survey was administered to 3800 registered students. Then, we identified a subset of 200 children with the most positive screening results for asthma. Next, a 32-item self-completion questionnaire was administered to this cohort. Students were surveyed regarding severity of asthma, perceptions and attitudes, and demographic information. Differences in proportions were tested by Chi-square analyses. Pearson rank-order correlation and multiple logistic regression were used to assess the relationship between perceptions and attitudes to self-treatment.

RESULTS

A total of 160 (80%) students participated. Mean age was 15.7 years. Of the respondents, 63% were female. 68% were Hispanic, 26% were African American. 33% had weekly symptoms, and 14% had daily symptoms. Additionally, 41% did not know the name of their asthma medicine. Only 38% reported bringing an "asthma pump" when leaving the house. While 70% reported feeling in control over their asthma symptoms, 63% reported feelings of anxiety and 39% could remember a time when they felt like they were going to die from asthma. Subjects who reported feeling in control over their asthma were more likely to take an asthma pump with them when leaving the house (r = 72, p = 0.004). Only 39% had disclosed their asthma to their friends, and 29% felt embarrassed about having an asthma attack in front of their friends. Subjects who felt embarrassed about their asthma were significantly less likely to take their asthma pumps with them (r = 0.98, p < 0.001) and less likely to use their medications in front of their friends (r = .87, p < 0.001).

CONCLUSIONS

Adolescents in this study reported feelings of anxiety, fear, and embarrassment about their asthma. Feelings of control over asthma symptoms were associated with positive attitudes toward self-treatment, while embarrassment was correlated with negative attitudes. These findings have implications for counseling adolescents with asthma about self-management strategies.

Drug compliance in adolescents: assessing and managing modifiable risk factors

Many studies have found that adolescence represents a problem in compliance with prescribed drug regimens. Multiple factors contribute to this problem, including the developmental evolution taking place in the adolescent physique and psyche. Health belief and patient demographic factors, inherent disease and regimen factors, as well as the dynamics between patient and provider may also contribute to problems with compliance to treatment. Simple interventions such as working with the teen to construct a tolerable treatment regimen, assessing anticipated compliance, discussing potential adverse effects, and establishing cues from the adolescent's daily routine can positively impact treatment compliance. Healthcare providers should recognize the fact that psychosocial changes in an adolescent's life can impact upon compliance with medications and enlist the help of their patients in constructing treatment regimens taking into account the individual's lifestyle that may impact upon compliance. In particular, the healthcare provider should ask the adolescents what they anticipate their success with compliance to treatment might be, adverse effects they are concerned about and what cues could best aid the treatment plan. The healthcare provider should then synthesize this information to create the best treatment plan for that patient.

A look at asthma care in a university setting

Is campus-based asthma care meeting students' needs? In this study, we examined asthma severity, impact, and quality of care in a sample of university students. Our research highlights the importance of designing university asthma programs specific to the needs of young adults that follow national asthma guidelines.

Motivation as a crucial predictor of good compliance in adolescents with rheumatoid arthritis

The purpose of this study was to identify the predictors of compliance shown by adolescents with juvenile rheumatoid arthritis (JRA). Three hundred individuals aged 13-17 years were randomly selected from the Finnish Social Insurance Institution's register. The questionnaires were sent to the adolescents selected from the register to be returned directly to the researcher in a self-addressed envelope. Ninety-one per cent (n = 274) returned the questionnaire. Logistic regression was used to find the factors that predicted compliance with health regimens. The compliance of adolescents with JRA was predicted on the basis of motivation, fear of acute problems, support from nurses, energy and willpower, and threat to social well-being. The most powerful predictor was motivation. The likelihood of the adolescents who had good motivation to comply with health regimens was 29.13-fold compared to the adolescents who did not have good motivation. The next powerful predictor was fear of acute problems. The adolescents who felt fear of acute problems complied with health regimens with a 20.35-fold likelihood compared to the adolescents who did not have fears. The third powerful predictor was support from nurses. The likelihood of adolescents supported by nurse to comply with health regimens was 17.03-fold compared to the adolescents who did not receive support from nurses. The likelihood of adolescents who had energy and willpower to comply with health regimens was 7.56-fold compared to the adolescents who did not have energy and willpower. Also, the threat to social well-being predicted good compliance.

Decision-making in children with asthma and their parents

PURPOSE

To learn how children with asthma and their parents make treatment-related decisions.

DATA SOURCES

Verbatim transcripts of focus group interviews of 28 school age children with asthma and their parents. Children had attended an educationally based asthma camp program. Questions related to choices parents and children made regarding implementation of their asthma treatment plans both, at home and at school.

CONCLUSIONS

Parents and children made many non-adherence decisions especially with respect to preventive aspects of the treatment plan. Symptoms were the driving force for children's decisions. Parents and children had concerns about implementing the management plan at school. Parents and children may not perceive asthma treatment options as true choices, thus affecting motivation for adherence.

IMPLICATIONS

Practitioners need to form partnerships with parents and children in developing treatment goals. Goals should focus on achievement of normal daily activities. Asthma education needs to be concrete and include school personnel. Practitioners need to give families positive, informational feedback.

Intentional and unintentional nonadherence: a study of decision making

Nonadherence to medical regimens is a major problem in health care. Distinguishing between intentional nonadherence (missing/altering doses to suit one's needs) and unintentional nonadherence (forgetting to take medication) may help in understanding nonadherence. Participants with respiratory conditions completed an anonymous questionnaire about (i) nonadherence; (ii) reasons for and against taking medications; and (iii) perceived style of the consultation in which their medication was first prescribed, as well as demographic and clinical variables. Consistent with the hypotheses, intentional nonadherence is predicted by the balance of individuals' reasons for and against taking medication as suggested by the Utility Theory, where these reasons include only those which the individual considers relevant and on which he/she focuses. Unintentional nonadherence is less strongly associated with decision balance, and more so with demographics. The research highlights the importance of (a) treating intentional and unintentional nonadherence as separate entities and (b) assessing individuals' idiosyncratic beliefs when considering intentional nonadherence.

Predicting adherence to prophylactic medication in adolescents with asthma: an application of the ASE-model

An explanatory framework, referred to as the attitude/social influence/self-efficacy-model (ASE-model), was utilised to explain future self-reported adherence of adolescents to daily inhaled prophylactic asthma medication. The objective was to investigate the long-term influence of these earlier reported cognitive variables and other psychological and medical determinants on self-reported adherence 1 year later. Data were collected, via a questionnaire, from 86 adolescents with asthma (aged 11 through 18 years) recruited from outpatient clinics. Adherence was assessed by asking the patients to give themselves a report mark for adherence. The results of the multiple regression analyses showed that the three major ASE-variables were predictors of self-reported adherence to a moderate degree (R(2)=0.21). Previous self-reported adherence was found to be the best predictor of self-reported adherence to prophylactic asthma medication 1 year later (R(2)=0.45). The results of this study could be useful in the development of interventions to enhance adherence to asthma medication. In future, such interventions should focus on feelings of shame about having asthma and promoting healthy habits, such as adherence to medication.

Enhancing medication adherence among inner-city children with asthma: results from pilot studies

Despite the availability of effective treatments that aid in controlling asthma symptoms, inner-city children with asthma have high rates of morbidity and are frequent users of emergency department services. The goal of these studies was to pilot test an intervention that used social learning strategies (e.g., goal-setting, monitoring, feedback, reinforcement, and enhanced self-efficacy) and targeted known barriers to individualize a family-based asthma action plan. Participants were 15 children with asthma, aged 7-12 years, who had been prescribed at least one daily inhaled steroid. The children and their mothers lived in inner-city Baltimore and all were African-American. Participants received up to five visits in their home by a nurse. Electronic monitors were installed on the children's MDI to provide immediate feedback on medication adherence to the families and validate medication use. At baseline, only 28.6% of the children were using their medications as prescribed. Within four weeks, the number of children who were using their medications appropriately doubled from 28.6% at baseline to 54.1% (90% increase; p = 0.004), while underutilization decreased from 51.2% to 25.4% (100% decrease; p = 0.02). The number of children with no medication use at all dropped from 28.3% at baseline to 15.1% by week 5 (87% decrease; p = 0.009). Thus, within four weeks, more than half the children were using their inhaled steroids appropriately. In addition, the rate of underutilization decreased and that of nonutilization was cut in half. Our initial data suggest that an individualized, home-based intervention can significantly enhance adherence to the daily use of inhaled steroids in inner-city children with asthma. Nevertheless, adherence to daily inhaled steroid therapy remains a significant problem in this group.

Predictors of good compliance in adolescents with epilepsy

The purpose of this paper was to describe the factors that predict compliance in adolescents with epilepsy. Altogether 300 individuals aged 13-17 years were randomly selected from the Finnish Social Insurance Institution's register. Every fifth person on the list was included in the sample. Seventy-seven per cent (N= 232 ) of the selected adolescents with epilepsy returned the questionnaire. The data were analysed with SPSS software. Using the logistic regression model, the compliance of adolescents with epilepsy was predicted on the basis of support from physician and parents, motivation and the disease not being a threat of social well-being. The most powerful predictor was support from the physician. The likelihood of adolescents supported by their physicians complying with their health regimens was 10.56-fold compared with the adolescents who did not receive support from their physicians. Another powerful predictor was support from parents. The adolescents who received support from their parents complied with the health regimens with a 10.47-fold likelihood compared with adolescents who did not receive support from their parents. Adolescents with good motivation were 9.77 times more likely to comply than adolescents who did not have good motivation. Adolescents who did not feel the disease to be a threat to their social well-being complied with health regimens with an 8.38-fold likelihood compared to those who felt the disease to be a threat to social well-being. The value of the -2Log likelihood was 64.68 and the goodness of fit index was 214.735. The value of Nagelkerke was 0.893, which indicates that the logistic regression model explains 89% of the variance. The model predicts correctly 97% of compliance in adolescents showing good compliance. These values show the logistic regression model to be good and to match well with the data.

Improving pediatric asthma patient outcomes by incorporation of effective interventions

Asthma affects approximately 5 million children in the United States. This disease results in billions of dollars of expenditures for hospitalizations, emergency admissions, medications, equipment, and indirect costs such as lost work productivity. This article describes how children with asthma received in-depth evaluations and education, long-term control medications, and Air Watch monitoring to improve treatment adherence, asthma control, and asthma severity. Study patients (n = 99) received patient care and education according to the protocols of the Pediatric Asthma Clinic, Lovelace Health Systems (Albuquerque, NM). All enrolled patients were prescribed fluticasone propionate and salmeterol xinafoate based on asthma severity and the National Institutes of Health guidelines. In addition, each patient used the AirWatch electronic airway monitoring system. Patients (n = 80) who participated in the study for 6 months demonstrated overall improved adherence to prescribed medications and better control of asthma. Adherence to the AirWatch system decreased over time, most likely due to improvements in the way the patients felt. In conclusion, treatment adherence, asthma control, and asthma severity can be improved with comprehensive patient education, long-term control medications, and objective home pulmonary function monitoring.

Support as a crucial predictor of good compliance of adolescents with a chronic disease

The purpose of this study was to describe the factors that predict compliance among adolescents with a chronic illness. The data were collected by questionnaires from adolescents with asthma, epilepsy, juvenile rheumatoid arthritis (JRA) and insulin-dependent diabetes mellitus (IDDM). Groups of 300 adolescents with these illnesses were selected from the Finnish Social Insurance Institution's register, giving a total study series of 1200 individuals. The final response percentage was 88% (n = 1061). The data were analysed with the SPSS software. Logistic regression was used to indicate the predictors of good compliance. The compliance of adolescents with a chronic disease was predicted on the basis of support from parents, nurses, physicians and friends, as well as motivation, energy and willpower. The most powerful predictor was support from nurses. The likelihood of adolescents supported by nurses complying with health regimens was 7.28-fold compared to the adolescents who did not receive support from nurses. The next powerful predictor was energy and willpower. Adolescents who had the energy and willpower to take care of themselves complied with health regimens with a 6.69-fold likelihood compared to the adolescents who did not have energy and willpower. Adolescents who had good motivation were 5.28 times more likely to comply than the adolescents who did not have motivation. Support from parents, physicians and friends similarly predicted good compliance with health regimens.

An intervention programme using the ASE-model aimed at enhancing adherence in adolescents with asthma

A randomised controlled trial, involving 112 adolescents with asthma, and a 2-year follow-up was conducted to assess the impact of an intervention programme aimed at enhancing adherence to asthma medication. This programme had a duration of 1 year and consisted of an experimental group which received usual care from a paediatrician, but additionally attended individual and group sessions with an asthma nurse, and a control group which received usual care only. The programme aimed at enhancing adherence by stimulating a positive attitude, increasing feelings of social support, and enhancing self-efficacy. At baseline, and after 12-month (T1) and 24-month (T2) follow-up, the participants filled in questionnaires which were based on the concepts of the ASE-model. Adherence was assessed by self-report (range: 1-10) at the same points in time. After 12 months, 97 adolescents (87%) were available for follow-up, decreasing to 86 adolescents (77%) after 24 months. No statistically significant differences were found between the control and the experimental group, except for one. At T2, self-reported adherence appeared to be statistically significantly higher in the experimental group. In conclusion, there seems to have been no substantial effect of the intervention programme.

Adherence to asthma therapy

OBJECTIVE

This article presents information on the important impact the lack of adherence to prescribed treatments has on the morbidity and mortality of asthma. After reading this article, readers should have an understanding of the significant role clinicians, as well as patients and their families, play in promoting adherence.

DATA SOURCES

A detailed literature search was conducted. Relevant studies were used. Only literature in the English language was reviewed.

STUDY SELECTION

Material was taken from academic/scholarly publications, appropriate reviews, and published abstracts.

RESULTS

Over the last decade, many researchers have examined ways to improve adherence to asthma therapy, including improving clinician-patient communication, educating the patient, and simplifying the treatment regimen. Nonadherence is a problem in pediatric and adolescent patients, whose needs are different from those of adult patients. Because proper technique is essential with metered-dose inhalers and peak flow meters, special efforts are required by clinicians to promote adherence to these devices.

CONCLUSIONS

Promoting adherence involves a good clinician-patient relationship, as well as provision of personalized, practical, and repeated education.