Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views

Evaluation of the Acceptability of a Proposed, Instagram-Based, Randomized Controlled Trial for People With Asthma: Survey Study

BACKGROUND

Asthma is a chronic lung disease that affects nearly 25 million individuals in the United States. More research is needed into the potential for health care providers to leverage existing social media platforms to improve healthy behaviors and support individuals living with chronic health conditions.

OBJECTIVE

In this study, we assessed the willingness of Instagram users with poorly controlled asthma to participate in a pilot randomized controlled trial that will use Instagram as a means of providing social and informational support. In addition, we explored the potential for adapting the principles of photovoice and digital storytelling to Instagram.

METHODS

We conducted a survey study of Instagram users aged 18-40 years with poorly controlled asthma in the United States.

RESULTS

Over 3 weeks of recruitment, 457 individuals completed the presurvey screener; 347 (75.9%) were excluded and 110 (24.1%) were eligible and agreed to participate in the study. Of the 110 individuals, 82 (74.5%) completed the study survey. The mean age of the respondents was 21 (SD 5.3) years. Among respondents, 56% (46/82) were female, 65% (53/82) were non-Hispanic White, and 72% (59/82) had at least some college education. The majority of respondents (67/82, 82%) indicated that they would be willing to participate in the proposed study.

CONCLUSIONS

Among young adult Instagram users with asthma, there is substantial interest in participating in a pilot randomized controlled trial that will use Instagram to connect participants with peers and a health coach to share information about self-management of asthma and build social connection.

Insights into how Malaysian adults with limited health literacy self-manage and live with asthma: A Photovoice qualitative study

BACKGROUND

Adjusting to life with a chronic condition is challenging, especially for people with limited health literacy, which is associated with low compliance with self-management activities and poor clinical outcomes.

OBJECTIVE

We explored how people with limited health literacy understand asthma and undertake self-management practices.

DESIGN

We adapted the arts-based qualitative methodology Photovoice.

SETTING AND PARTICIPANTS

We sampled ethnically diverse adults with asthma and limited health literacy from four primary healthcare clinics in Malaysia. After a semistructured in-depth interview, a subset of participants took part in the Photovoice component in which participants undertook a 2-week photo-taking activity and subsequent photo-interview. Interviews, conducted in participants' preferred language, were audio-recorded, transcribed verbatim, translated and analysed thematically. We used the Sorensen's framework (Domains: access, understand, appraise, apply) to describe participants' experience of living with asthma, what they understood about asthma and how they decided on self-management practices.

RESULTS

Twenty-six participants provided interviews; eight completed the Photovoice activities. Participants with limited health literacy used various sources to access information about asthma and self-management. Doctor-patient communication had a pivotal role in helping patients understand asthma. The lack of appraisal skills was significant and experiential knowledge influenced how they applied information. Self-management decisions were influenced by sociocultural norms/practices, stigmatizing experiences, and available social support.

CONCLUSION

Locally tailored multilevel interventions (interpersonal, health system, community and policy) will be needed to support people with limited health literacy to live optimally with their asthma in an ethnically diverse population.

PATIENT/PUBLIC CONTRIBUTION

Patients were involved in the study design, recruitment, analysis and dissemination.

Self-management support preferences of people with asthma or chronic obstructive pulmonary disease: A systematic review and meta-synthesis of qualitative studies

OBJECTIVES

To synthesise findings from qualitative studies on the preferences of people with asthma or chronic obstructive pulmonary disease (COPD) for self-management support.

METHODS

A thematic synthesis of literature was carried out. Six databases (ASSIA, CINAHL, MEDLINE, PsycINFO, Psychology and the Behavioural Sciences and SSCI) were used to search for qualitative studies eliciting perspectives of adults with asthma and/or COPD on self-management support, published between May 2008 and April 2018.

RESULTS

A total of 968 articles were retrieved across databases, with 15 articles included in the synthesis. Three themes were identified: Types of Support described the range of supports valued by participants in the studies, particularly education provided by competent healthcare professionals; The Support Relationship highlighted the importance of a collaborative relationship with one's healthcare professional which was characterised by communication, trust and continuity over time and Accessibility identified the considerations of participants relating to physically accessible, prompt support which is provided in a format preferred by the individual.

DISCUSSION

Increased understanding of patients' preferences may provide insight which can be used to enhance engagement with self-management support. Further research needs to examine self-management support preferences outside the context of evaluating interventions for people with asthma/COPD and needs to address the optimal means of enhancing accessibility.

A feasibility trial of a digital mindfulness-based intervention to improve asthma-related quality of life for primary care patients with asthma

Asthma outcomes remain suboptimal, despite effective pharmacotherapy. Psychological dysfunction (such as anxiety) is common, and associated with poorer outcomes. We evaluated a digital mindfulness programme as an intervention to improve asthma-related quality of life for primary care patients, in a prospectively registered randomized-controlled feasibility study. We offered ‘Headspace’, a widely-used digital mindfulness intervention, to adults with asthma through 16 UK GP practices. Participants were randomized on a 2:1 basis to the mindfulness intervention, or waitlist control. Participants completed questionnaires (including asthma symptom control, asthma-related quality of life, anxiety, depression) at baseline, 6-week and 3-month follow-up. 116 participants completed primary outcomes at 3-month follow-up: intervention 73 (79%), control 43 (84%). Compared to baseline, the intervention group but not the control group reported significantly improved asthma-related quality of life, with a between-group difference favoring the intervention group that was not significant (Mean difference = 0.15, 95%CI − 0.13 to 0.42). Intervention use varied (ranging from 0 to 192 times) but was generally high. Digital mindfulness interventions are feasible and acceptable adjunct treatments for mild and moderate asthma to target quality of life. Further research should adapt ‘generic’ mindfulness-based stress-reduction to maximize effectiveness for asthma, and validate our findings in a fully-powered randomized controlled trial.

Trial registration Prospectively registered: ISRCTN52212323.

A Systematic Review on Mobile Health Applications' Education Program for Patients Taking Oral Anticoagulants

Warfarin is widely used as an oral anticoagulant. However, it is difficult to manage patients due to its narrow therapeutic range and individualized differences. Using controlled trials and real-world observational studies, this systematic review aimed to analyze health education’s impact among patients on warfarin therapy by mobile application. Smartphone and tablet applications have the potential to actively educate patients by providing them with timely information through push notifications. MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane electronic databases were searched using the keywords “anticoagulants,” “warfarin”, “mobile application”, and “smartphone” up to May 2020. Of the 414 articles obtained, 12 articles met the inclusion criteria for this review. The education and self-management programs using the mobile health application had diverse contents. A meta-analysis was not deemed appropriate because of the heterogeneity of populations, interventions, and outcomes. Thus, a narrative synthesis is presented instead. This review demonstrates that educating patients for anticoagulation management through their smartphones or tablets improves their knowledge levels, medication or treatment adherence, satisfaction, and clinical outcomes. Moreover, it has a positive effect on continuing health care. Future research concerning patients taking warfarin should include key self-management outcomes in larger, more rigorously designed studies, allowing for comparisons across studies. This study proposes a continuous application of timely education through smartphone applications to the current medical and nursing practice.

Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals

Asthma self-management is a crucial component of asthma management. We sought to explore healthcare professionals' (HCPs') perceptions on barriers to asthma self-management implementation in primary care. We recruited 26 HCPs from six public primary care clinics in a semi-urban district of Malaysia in 2019. The analysis was done inductively. HCPs described barriers that resonated with the "COM-B" behaviour change framework. Capability-related issues stemmed from a need for specific self-management skills training. Opportunity-related barriers included the need to balance competing tasks and limited, poorly tailored resources. Motivation-related barriers included lack of awareness about self-management benefits, which was not prioritised in consultations with perceived lack of receptiveness from patients. These were compounded by contextual barriers of the healthcare organisation and multilingual society. The approach to implementation of asthma self-management needs to be comprehensive, addressing systemic, professional, and patient barriers and tailored to the local language, health literacy, and societal context.

Community knowledge and attitude in recognizing asthma symptoms and using medication for asthma attacks: a cross-sectional study

OBJECTIVES

Uncontrolled asthma may be life-threatening. Poor understanding of disease process and appropriate medication use appears to influence community attitude in facing asthmatic patients in an emergency, thereby contributing to increasing the risk of mortality. This study aimed to analyze community-level knowledge about asthma and attitude towards asthma management.

METHODS

This observational, cross-sectional study was conducted among the community in Gresik, Indonesia, from March to July 2019. Participants included in this study were adults, who could read, write, and communicate well. Data were collected through questionnaires to evaluate the level of knowledge and attitude towards asthma.

RESULTS

In total, 100 respondents were selected with 91% of women, with a mean age of 49.11 ± 14.42 years and with various levels of education. The respondents had good knowledge by getting a score of 76%. Knowledge regarding recognition of asthma symptoms was scored the highest (83%). However, knowledge about medication use for asthma was lacking, especially in identifying the medicine choice (21%) and inhaler use (48%). The respondents also showed a 'positive' attitude with a score of 89%. Most respondents (72%) agreed that when inhaled drugs were unable to relieve the asthma attack, they need to bring the patient to a hospital.

CONCLUSIONS

The level of respondent's knowledge in recognizing asthma symptoms was good, but there were misconceptions about asthma medication, especially in inhaler use. Overall, the respondents had a positive attitude towards asthma perception and management.

Factors affecting self-management in Iranian tuberculosis patients: A path analysis model

Background

Self-management behaviors can reduce the progression of an illness. Although various factors affect self-management, no study has been conducted on the self-management of tuberculosis (TB) through path analysis.

Objectives

This study evaluated the factors affecting self-management in TB patients using path analysis.

Methods

A cross-sectional study was done on 133 non-prisoner TB patients that referred to all health centers in Karaj, Iran, in 2017. A structured questionnaire was applied. Data were analyzed with SPSS-17 and Lisrel 8.8, utilizing statistical path analysis to evaluate the relationships between self-management and its related factors.

Results

Overall, 52.3% of the participants in the study were female and 47.7% were male. Respondents of were 46.9% smear-positive, 9.4% smear-negative, and 43.8% extra-pulmonary TB. Fit indices confirmed the model fitness and logical relationships between the variables according to the conceptual model (χ² = 49.80, df = 25). The final path model showed that age (β = 0.84), attitude (β = 0.10), marital status (β = 0.04), and house condition (β = 0.03) impact self-management through the direct path. Knowledge (β = 0.83) and education (β = 0.16) affect self-management through both direct and indirect paths. Education indirectly affects self-management through both knowledge and attitude. Knowledge indirectly impacts self-management through attitude. In other words, knowledge and attitude mediate the relationship between some factors and self-management.

Conclusions

This study provided an empirical model that illustrates the relationships between self-management and related factors in TB patients. The knowledge can be the target of interventions in support of self-management.

Factors affecting healthcare pathways for chronic lung disease management in Vietnam: a qualitative study on patients' perspectives

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and asthma rank among the leading causes of respiratory morbidity, particularly in low- and middle-income countries. This qualitative study aimed to explore the healthcare pathways of patients with chronic respiratory disease, and factors influencing their ability to access healthcare in Vietnam, where COPD and asthma are prevalent.

METHODS

We conducted 41 in-depth interviews among patients, including 31 people with COPD, eight with asthma and two with asthma-COPD overlap syndrome. Participants were recruited at provincial- or national-level health facilities in two urban and two rural provinces in Vietnam. The interviews were audio-recorded, transcribed, and analysed using thematic analysis.

RESULTS

Patients' healthcare pathways were complex and involved visits to multiple health facilities before finally obtaining a definitive diagnosis at a provincial- or national-level hospital. Access to healthcare was affected considerably by participants' limited knowledge of their respiratory conditions, the availability of social support, especially from family members, the costs of healthcare as well as health system factors (including the coverage of public health insurance, the distance to health facilities, and attitude of healthcare providers).

CONCLUSION

The study demonstrated the need for improved access to timely diagnosis and treatment of chronic lung disease within the lower level of the health system. This can be achieved by enhancing the communication skills and diagnostic capacity of local healthcare workers. Health education programmes for patients and caregivers will contribute to improved control of lung disease.

Initial Validation of IBD KNOW-IT: Measuring Patient and Caregiver Knowledge of a Child's Disease and Treatment Regimen

The present study describes the development and initial validation of a newly developed measure of child and caregiver knowledge of the child's own IBD and treatment, called IBD KNOW-IT. One hundred and fifty-five children and their caregivers completed the IBD KNOW-IT as well as a scale designed to compare each dyad's perceived knowledge to their actual knowledge. Initial psychometric evaluation of IBD KNOW-IT was completed by conducting factor analysis and determining internal consistency, convergent validity, and associations with demographic and medical characteristics. Results supported the validity of a 12-item measure with 4 subscales including Symptoms, Medication Regimen, Disease Monitoring, and Medical Team. Support for the internal consistency of IBD KNOW-IT was obtained. Evidence of validity was demonstrated by significant correlations between child and caregiver scales, and high congruence between perceived and actual knowledge across all subscales. The reliability of the measure was demonstrated by good internal consistency and test-retest reliability. Preliminary psychometric evaluation suggests that IBD KNOW-IT is reliable and valid.

Atrial fibrillation self-management: a mobile telephone app scoping review and content analysis

Atrial fibrillation (AF) affects over 1.4 million people in the UK, resulting in a five-fold increased stroke risk and a three to four times greater risk of severe, disabling stroke. Atrial fibrillation, a chronic disease, requires monitoring, medication, and lifestyle measures. A self-management approach supported by mobile health (mHealth) may empower AF self-care. To assess the need to develop new mHealth self-management interventions for those with AF this review aimed to identify commercially available AF self-management apps, analyse, and synthesize (i) characteristics, (ii) functions, (iii) privacy/security, (iv) incorporated behaviour change techniques (BCTs), and (v) quality and usability. We searched app stores for 'atrial fibrillation' and 'anticoagulation', and included apps focused on AF self-management in the review. We examined app functions, privacy statements against best practice recommendations, the inclusion of BCTs using the App Behaviour Change Scale, and app quality/usability using the Mobile App Rating Scale. From an initial search of 555 apps, five apps were included in the review. Common functions were educational content, medication trackers, and communication with healthcare professionals. Apps contained limited BCTs, lacked intuitive functions and were difficult to use. Privacy policies were difficult to read. App quality rated from poor to acceptable and no app had been evaluated in a clinical trial. The review reports a lack of commercially available AF self-management apps of sufficient standard for use in healthcare settings. This highlights the need for clinically validated mHealth interventions incorporating evidence-based BCTs to support AF self-management.

Physician's perspective regarding asthma guided self-management: directives or guidance?

INTRODUCTION

Asthma guided self-management enhances patients' control of their condition under the guidance of the treating physician. The aim of the present study was to understand how physicians perceive, endorse, uptake, and support asthma guided self-management.

METHODS

We conducted a secondary supplementary analysis of data originally collected as part of a multicenter collective case study in which physicians treating patients with asthma were interviewed. Using reflective thematic analysis, we aimed to explore physicians' understanding of guided asthma self-management as related to four ideas, namely: (a) understanding of the disease management and treatment goals; (b) defining medical frame and guidance; (c) describing the importance of patient-physician relationship; and (d) implementing asthma guided self-management.

RESULTS

Evidence indicates that physicians perceived optimal guided self-management as related to patients' adherence to physician's instructions and recommendations, supported by the adjustment of prescribed pharmaceutical therapy contingent upon patient's symptoms. Some physicians also perceived behavior change and environmental control along with the medical recommendations. While physicians' perception of asthma and its treatment were aligned with the recommended guidelines-i.e., patient-centered care approach based on guided self-management, the actual guidance offered to patients remained primarily directive and paternalistic. Non-pharmacological approaches, such as exercise, smoking cessation, patient self-monitoring, and self-management supported by education and written self-management plans, were given little consideration in the context of the recommended treatment plan.

Developing theory-based asthma self-management interventions for South Asians and African Americans: A systematic review

PURPOSE

Intervention development guidelines suggest that behavioural interventions benefit from being theory-based. Minority populations typically benefit less from asthma self-management interventions, and the extent to which appropriate theory has been used for culturally tailored interventions has not been addressed. We aimed to determine theory use and theoretical domains targeted in asthma self-management interventions for South Asian and Black populations.

METHODS

We systematically searched electronic databases, research registers, manually searched relevant journals and reference lists of reviews for randomised controlled trials of asthma self-management for South Asian and Black populations, and extracted data using the Theory Coding Scheme to inform if/how theory was used and explore its associations with asthma outcomes, and the Theoretical Domains Framework was used to identify targeted theoretical domains and its relationship to effectiveness of asthma outcomes.

RESULTS

20 papers (19 trials) were identified; theory was not extensively used in interventions. It was unclear whether theory use or theoretical domains targeted in interventions improved asthma outcomes. South Asian interventions included 'behavioural regulation', while 'reinforcement' was mostly used in African American interventions. 'Knowledge' was central for all populations, though there were differences related to 'environmental context and resources' e.g., language adaptations for South Asians; asthma resources provided for African Americans. Author descriptions of interventions targeting providers were limited.

CONCLUSIONS

There was little evidence of theory-based approaches used in cultural interventions for asthma self-management. Demystifying theoretical concepts (and cultural interpretations of constructs) may provide clarity for 'non-experts', enabling mainstream use of theory-driven approaches in intervention development.

Conversational Agents as Mediating Social Actors in Chronic Disease Management Involving Health Care Professionals, Patients, and Family Members: Multisite Single-Arm Feasibility Study

BACKGROUND

Successful management of chronic diseases requires a trustful collaboration between health care professionals, patients, and family members. Scalable conversational agents, designed to assist health care professionals, may play a significant role in supporting this collaboration in a scalable way by reaching out to the everyday lives of patients and their family members. However, to date, it remains unclear whether conversational agents, in such a role, would be accepted and whether they can support this multistakeholder collaboration.

OBJECTIVE

With asthma in children representing a relevant target of chronic disease management, this study had the following objectives: (1) to describe the design of MAX, a conversational agent-delivered asthma intervention that supports health care professionals targeting child-parent teams in their everyday lives; and (2) to assess the (a) reach of MAX, (b) conversational agent-patient working alliance, (c) acceptance of MAX, (d) intervention completion rate, (e) cognitive and behavioral outcomes, and (f) human effort and responsiveness of health care professionals in primary and secondary care settings.

METHODS

MAX was designed to increase cognitive skills (ie, knowledge about asthma) and behavioral skills (ie, inhalation technique) in 10-15-year-olds with asthma, and enables support by a health professional and a family member. To this end, three design goals guided the development: (1) to build a conversational agent-patient working alliance; (2) to offer hybrid (human- and conversational agent-supported) ubiquitous coaching; and (3) to provide an intervention with high experiential value. An interdisciplinary team of computer scientists, asthma experts, and young patients with their parents developed the intervention collaboratively. The conversational agent communicates with health care professionals via email, with patients via a mobile chat app, and with a family member via SMS text messaging. A single-arm feasibility study in primary and secondary care settings was performed to assess MAX.

RESULTS

Results indicated an overall positive evaluation of MAX with respect to its reach (49.5%, 49/99 of recruited and eligible patient-family member teams participated), a strong patient-conversational agent working alliance, and high acceptance by all relevant stakeholders. Moreover, MAX led to improved cognitive and behavioral skills and an intervention completion rate of 75.5%. Family members supported the patients in 269 out of 275 (97.8%) coaching sessions. Most of the conversational turns (99.5%) were conducted between patients and the conversational agent as opposed to between patients and health care professionals, thus indicating the scalability of MAX. In addition, it took health care professionals less than 4 minutes to assess the inhalation technique and 3 days to deliver related feedback to the patients. Several suggestions for improvement were made.

CONCLUSIONS

This study provides the first evidence that conversational agents, designed as mediating social actors involving health care professionals, patients, and family members, are not only accepted in such a "team player" role but also show potential to improve health-relevant outcomes in chronic disease management.

Profiling Persistent Asthma Phenotypes in Adolescents: A Longitudinal Diagnostic Evaluation from the INSPIRERS Studies

We aimed to identify persistent asthma phenotypes among adolescents and to evaluate longitudinally asthma-related outcomes across phenotypes. Adolescents (13–17 years) from the prospective, observational, and multicenter INSPIRERS studies, conducted in Portugal and Spain, were included (n = 162). Latent class analysis was applied to demographic, environmental, and clinical variables, collected at a baseline medical visit. Longitudinal differences in clinical variables were assessed at a 4-month follow-up telephone contact (n = 128). Three classes/phenotypes of persistent asthma were identified. Adolescents in class 1 (n = 87) were highly symptomatic at baseline and presented the highest number of unscheduled healthcare visits per month and exacerbations per month, both at baseline and follow-up. Class 2 (n = 32) was characterized by female predominance, more frequent obesity, and uncontrolled upper/lower airways symptoms at baseline. At follow-up, there was a significant increase in the proportion of controlled lower airway symptoms (p < 0.001). Class 3 (n = 43) included mostly males with controlled lower airways symptoms; at follow-up, while keeping symptom control, there was a significant increase in exacerbations/month (p = 0.015). We have identified distinct phenotypes of persistent asthma in adolescents with different patterns in longitudinal asthma-related outcomes, supporting the importance of profiling asthma phenotypes in predicting disease outcomes that might inform targeted interventions and reduce future risk.

The Effectiveness of a Family-Based Asthma Self-Management Program in Enhancing the Asthma Health Outcomes in School-Age Children

This quasi-experimental study aimed to evaluate a family-based asthma self-management program, based on the individual and family self-management theory and the McMaster model of family functioning. Children aged 7 to 12 with uncontrolled asthma and their families were recruited from an outpatient pulmonary department of a university hospital in Thailand. Thirty-seven child-parent pairs were randomly assigned to three sessions for a period of two months of the family-based asthma self-management program, while 37 child-parent pairs were assigned to the control group. Data were collected at baseline and after implementation at two months by using the Childhood Asthma Control Questionnaire and the Pediatric Asthma Quality of Life Questionnaire, and the measurement of pulmonary function was performed using peak flow meters. Multivariate analysis of covariance (MANCOVA) was employed to analyze the mean difference between the experimental and control groups. The results indicated significant increased asthma control status, pulmonary function, and quality of life in the children from baseline to after implementation in the experimental group that participated in the family-based asthma self-management program. Significant improvement in these three asthma health outcomes was also seen in the experimental group when compared to the control group. It was seen that the family-based asthma self-management program is useful for promoting the self-management of school-age children, enabling the control of symptoms, and enhancing health outcomes regarding asthma.

Nocturnal Cough and Sleep Quality to Assess Asthma Control and Predict Attacks

Introduction

Objective markers for asthma, that can be measured without extra patient effort, could mitigate current shortcomings in asthma monitoring. We investigated whether smartphone-recorded nocturnal cough and sleep quality can be utilized for the detection of periods with uncontrolled asthma or meaningful changes in asthma control and for the prediction of asthma attacks.

Methods

We analyzed questionnaire and sensor data of 79 adults with asthma. Data were collected in situ for 29 days by means of a smartphone. Sleep quality and nocturnal cough frequencies were measured every night with the Pittsburgh Sleep Quality Index and by manually annotating coughs from smartphone audio recordings. Primary endpoint was asthma control assessed with a weekly version of the Asthma Control Test. Secondary endpoint was self-reported asthma attacks.

Results

Mixed-effects regression analyses showed that nocturnal cough and sleep quality were statistically significantly associated with asthma control on a between- and within-patient level (p < 0.05). Decision trees indicated that sleep quality was more useful for detecting weeks with uncontrolled asthma (balanced accuracy (BAC) 68% vs 61%; Δ sensitivity −12%; Δ specificity −2%), while nocturnal cough better detected weeks with asthma control deteriorations (BAC 71% vs 56%; Δ sensitivity 3%; Δ specificity −34%). Cut-offs using both markers predicted asthma attacks up to five days ahead with BACs between 70% and 75% (sensitivities 75 - 88% and specificities 57 - 72%).

Conclusion

Nocturnal cough and sleep quality have useful properties as markers for asthma control and seem to have prognostic value for the early detection of asthma attacks. Due to the limited study duration per patient and the pragmatic nature of the study, future research is needed to comprehensively evaluate and externally validate the performance of both biomarkers and their utility for asthma self-management.

Integrating drawings into health curricula: university educators' perspectives

The literature has identified promising findings regarding the application of arts-based initiatives to enhance healthcare professional (HCP) training. Research shows that drawings offer a window into the authentic, insider view of health and illness, with potential to be a platform for healthcare student and HCP learning. In addition, drawings may also have a place in health communication. Our previous work provides support for the educational application of patients' drawings in bringing HCPs closer to the patient's lived experience. Subsequently, this study aimed to explore university educators' opinions regarding the implementation of drawings as an educational tool for higher education healthcare students. The objective of this study was to explore pathways for using drawings as an art form in an educational context, and provide recommendations for developing curricula and resources for further evaluation. Findings from focus group interviews with nine university educators revealed support for the use of drawings as a novel medium as they offer rich insights into the patient's perspective while encouraging creative and critical thinking. Key perceived benefits were that drawings foster student appreciation of (1) the holistic impact of illness, (2) the importance of patients' priorities and (3) the value of learning from the patient. Patients' drawings of their experiences would offer needed opportunities for students to explicitly reflect about the 'person' holistically rather than view the patient as a 'biomedical problem'. Shifting students' perspectives and possible assumptions to be better aligned with and appreciative of the patient's experiences was noted as central to adopting a person-centred approach to healthcare practice. Our findings suggest that incorporating drawings, or indeed other art forms, as educational tools would be a valuable addition to the health curricula.

Integrating a Web-Based Self-Management Tool (Managing Joint Pain on the Web and Through Resources) for People With Osteoarthritis-Related Joint Pain With a Web-Based Social Network Support Tool (Generating Engagement in Network Involvement): Design, Development, and Early Evaluation

BACKGROUND

Joint pain caused by osteoarthritis (OA) is highly prevalent and can be extremely debilitating. Programs to support self-management of joint pain can be effective; however, most programs are designed to build self-efficacy and rarely engage social networks. Digital interventions are considered acceptable by people with joint pain. However, many existing resources are not accessible for or developed alongside people with lower health literacy, which disproportionately affects people with OA.

OBJECTIVE

This study aims to design and develop an accessible digital self-management tool for people with joint pain and integrate this with an existing social network activation tool (Generating Engagement in Network Involvement [GENIE]) and to explore the feasibility of these linked tools for supporting the management of joint pain.

METHODS

The study was conducted in 2 phases: a design and development stage and a small-scale evaluation. The first phase followed the person-based approach to establish guiding principles for the development of a new site (Managing joint Pain On the Web and through Resources [EMPOWER]) and its integration with GENIE. People with joint pain were recruited from libraries, a community café, and an exercise scheme to take part in 3 focus groups. EMPOWER was tested and refined using think-aloud interviews (n=6). In the second phase, participants were recruited through the web via libraries to participate in a small-scale evaluation using the LifeGuide platform to record use over a 1-month period. Participants (n=6) were asked to complete evaluation questionnaires on their experiences. The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was used to explore the feasibility of the sites.

RESULTS

The focus groups established guiding principles for the development of the tool. These included ensuring accessibility and relevance for people with OA-related joint pain and recognizing that joint pain is the reason for seeking support, trust, social facilitation, and goal setting. Think-aloud interviews identified issues with user experience and site navigation and the need for professional input for referral and goal setting, confusion, and tensions over the role of GENIE and site connectivity. Participants expected the sites to be specific to their pain-related needs. EMPOWER was accessed 18 times; 6 users registered with the site during the evaluation study. Participants mostly explored information pages on being active and being a healthy weight. Only one participant undertook goal setting and 4 participants visited the GENIE website.

CONCLUSIONS

Using the NASSS framework, we identified the complexity associated with integrating EMPOWER and GENIE. The value proposition domain highlighted the technical and conceptual complexity associated with integrating approaches. Although identified as theoretically achievable, the integration of differing propositions may have caused cognitive and practical burdens for users. Nevertheless, we believe that both approaches have a distinct role in the self-management of joint pain.

Asthma and COVID-19: review of evidence on risks and management considerations

BACKGROUND

Respiratory illnesses typically present increased risks to people with asthma (PWA). However, data on the risks of COVID-19 to PWA have presented contradictory findings, with implications for asthma management.

OBJECTIVE

To assess the risks and management considerations of COVID-19 in people with asthma (PWA).

METHOD

We conducted a rapid literature review. We searched PubMed, medRxiv, LitCovid, TRIP, Google and Google Scholar for terms relating to asthma and COVID-19, and for systematic reviews related to specific management questions within our review, in April 2020. References were screened and data were extracted by one reviewer.

RESULTS

We extracted data from 139 references. The evidence available is limited, with some sources suggesting an under-representation of PWA in hospitalised cases and others showing an increased risk of worse outcomes in PWA, which may be associated with disease severity. Consensus broadly holds that asthma medications should be continued as usual. Almost all aspects of asthma care will be disrupted during the pandemic due not only to limits in face-to-face care but also to the fact that many of the diagnostic tools used in asthma are considered aerosol-generating procedures. Self-management and remote interventions may be of benefit for asthma care during this time but have not been tested in this context.

CONCLUSIONS

Evidence on COVID-19 and asthma is limited and continuing to emerge. More research is needed on the possible associations between asthma and COVID-19 infection and severity, as well as on interventions to support asthma care in light of constraints and disruptions to healthcare systems. We found no evidence regarding health inequalities, and this urgently needs to be addressed in the literature as the burdens of asthma and of COVID-19 are not equally distributed across the population.

Self-management interventions to reduce healthcare use and improve quality of life among patients with asthma: systematic review and network meta-analysis

OBJECTIVE

To compare the different self-management models (multidisciplinary case management, regularly supported self-management, and minimally supported self-management) and self-monitoring models against usual care and education to determine which are most effective at reducing healthcare use and improving quality of life in asthma.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, the Cochrane Library, CINAHL, EconLit, Embase, Health Economics Evaluations Database, NHS Economic Evaluation Database, PsycINFO, and ClinicalTrials.gov from January 2000 to April 2019.

REVIEW METHODS

Randomised controlled trials involving the different self-management models for asthma were included. The primary outcomes were healthcare use (hospital admission or emergency visit) and quality of life. Summary standardised mean differences (SMDs) and 95% credible intervals were estimated using bayesian network meta-analysis with random effects. Heterogeneity and publication bias were assessed.

RESULTS

From 1178 citations, 105 trials comprising 27 767 participants were included. In terms of healthcare use, both multidisciplinary case management (SMD -0.18, 95% credible interval -0.32 to -0.05) and regularly supported self-management (-0.30, -0.46 to -0.15) were significantly better than usual care. For quality of life, only regularly supported self-management (SMD 0.54, 0.11 to 0.96) showed a statistically significant benefit compared with usual care. For trials including adolescents/children (age 5-18 years), only regularly supported self-management showed statistically significant benefits (healthcare use: SMD -0.21, -0.40 to -0.03; quality of life: 0.23, 0.03 to 0.48). Multidisciplinary case management (SMD -0.32, -0.50 to -0.16) and regularly supported self-management (-0.32, -0.53 to -0.11) were most effective at reducing healthcare use in patients with symptoms of severe asthma at baseline.

CONCLUSIONS

This network meta-analysis indicates that regularly supported self-management reduces the use of healthcare resources and improves quality of life across all levels of asthma severity. Future healthcare investments should provide support that offer reviews totalling at least two hours to establish self-management skills, reserving multidisciplinary case management for patients with complex disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO number CRD42019121350.

Patient preferences for asthma management: a qualitative study

OBJECTIVE

Preference for asthma management and the use of medications is motivated by the interplay between lived experiences of asthma and patients' attitudes towards medications. Many previous studies have focused on individual aspects of asthma management, such as the use of preventer and reliever inhalers. The aim of this qualitative study was to explore the preferences of patients with mild-moderate asthma for asthma management as a whole and factors that influenced these preferences.

DESIGN

A qualitative study employing qualitative descriptive analysis situated within a constructionist epistemology to analyse transcribed audio recordings from focus groups.

SETTING

Three locations within the greater Wellington area in New Zealand.

PARTICIPANTS

Twenty-seven adults with self-reported doctor's diagnosis of asthma, taking short-acting beta-agonists alone or inhaled corticosteroids with or without long-acting beta2-agonist, who had used any inhaled asthma medication within the last month.

RESULTS

Four key areas described preferences for asthma management. Preferences for self-management: participants wanted to be in control of their asthma and developed personal strategies to achieve this. Preferences for the specific medications or treatment regimen: participants preferred regimens that were convenient and reliably relieved symptoms. Preferences for inhaler devices: devices that had dose counters and were easy to use and portable were important. Preferences for asthma services: participants wanted easier access to their inhalers and to be empowered by their healthcare providers. Participant preferences within each of these four areas were influenced by the impact asthma had on their life, their health beliefs, emotional consequences of asthma and perceived barriers to asthma management.

CONCLUSIONS

This study illustrates the interaction of the lived experience of asthma, factors specific to the individual, and factors relating to asthma treatments in shaping patient preferences for asthma management. This aids our understanding of preferences for asthma management from the patient perspective.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000601134).

Perceptions of childhood asthma and its control among Malays in Malaysia: a qualitative study

Children with poor asthma control have poor health outcomes. In Malaysia, the Malays have the highest asthma prevalence and poorest control compared to other ethnicities. We aimed to explore Malay children with asthma and their parents' perceptions on asthma and its control. We conducted focus group discussions (FGD) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Sixteen children and parents (N = 32) participated. The perception of asthma was based on personal experience, cultural and religious beliefs, and there was mismatch between children and parents. Parents perceived mild symptoms as normal, some had poor practices, raising safety concerns as children were dependent on them for self-management. Conflicting religious opinions on inhaler use during Ramadhan caused confusion in practice. Parents perceived a lack of system support towards asthma care and asthma affected quality of life. Urgent intervention is needed to address misconceptions to improve asthma care in children.

Bringing asthma care into the twenty-first century

Despite access to diagnostic tests and effective therapies, asthma often remains misdiagnosed and/or poorly controlled or uncontrolled. In this review, we address the key issues of asthma diagnosis and management, recent evidence for levels of asthma control, the consequences of poor control and, in line with that, explore the potential reasons for poor asthma control and acute exacerbations. Based on recent evidence and current guidelines, we also aim to provide practical answers to the key questions of how to improve asthma management, with the best possible prevention of exacerbations, addressing the basics-adherence, inhaler misuse, obesity and smoking-and how to facilitate a new era of asthma care in the twenty-first century. We hope this review will be useful to busy primary care clinicians in their future interactions with their patients with both suspected and proven asthma.

Perspectives on managing asthma and facilitators in asthma self-management among Thai school-age children: a qualitative study

Purpose

This study explored self-management in the context of asthma experiences of school-age children and the factors that facilitate asthma self-management.

Design/methodology/approach

This is qualitative research used in-depth interviews. Purposive sampling was employed to select 15 school-age children with asthma attending the outpatient pulmonary department at university hospital in Thailand. Semistructured in-depth individual interviews were conducted. which were audiotaped and transcribed verbatim. Content analysis was used to analyze the data.

Findings

Two major themes emerged from this study: (1) perspectives on managing asthma and (2) facilitators in asthma self-management. Four subthemes emerged from the first major theme related to views on managing asthma: (1) emphasizing use of an inhaler for asthma, (2) self-monitoring for symptom, (3) difficulties with the daily regimens and (4) family support on asthma self-management. Two subthemes emerged from the second major theme related to facilitators in asthma self-management: (1) confidence in performing asthma care behaviors and (2) asthma communication.

Originality/value

This study described strategies that support asthma management of children in Thailand and provided insight into factors that influence asthma self-management. Findings will inform the development of future self-management interventions for school-age children with asthma.

Adults With Asthma Experience No Increase in Asthma-related Exacerbations When Digital Communication Technology Tools Are Employed to Offset Provider Workload: A Pragmatic Randomized Trial

BACKGROUND

Challenges to health care efficiency are increasingly addressed with the help of digital communication technology tools (DCTs).

OBJECTIVE

The objective of this study was to test whether DCT, compared with Usual Care, can reduce health care clinician burden without increasing asthma-related exacerbations among patients with asthma in a large integrated health care system.

RESEARCH DESIGN

The (Breathewell) program was a pragmatic, randomized trial at (Kaiser Permanente Colorado), where asthma nurses screen patients for poor symptom control when beta2-agonist refill requests came within 60 days of previous fill or in the absence of a controller medication fill within 4 months (beta2-agonist overfill). A total of 14,978 adults with asthma were randomized to Usual Care or 1 of 2 DCT intervention groups (Text/Phone call or Email).

SUBJECTS

Participants included adults 18 and older with an asthma diagnosis at the time of randomization and no history of chronic obstructive pulmonary disease.

MEASURES

Primary outcome measures included asthma-related health care resource utilization (eg, asthma nurse contacts), medication use, and exacerbations.

RESULTS

A total of 1933 patients had 4337 events which met beta2-agonist overfill criteria. Of the 2874 events in the intervention arm, 1188 (41%) were resolved by DCT contact and did not require additional clinician contact. Asthma medication use and exacerbations over 12 months did not differ among the 3 groups.

CONCLUSIONS

DCT tools can successfully contact adult asthma patients to screen for symptoms and facilitate intervention. The absence of differences in medication fills and health care utilization indicates that the strategic replacement of nursing interventions by digital outreach did not reduce treatment adherence or compromise health care outcomes.

Development and Pretesting of a New Functional-Based Health Literacy Measurement Tool for Chronic Obstructive Pulmonary Disease (COPD) and Asthma Management

Background

Health literacy (HL) is a person’s ability to practically apply a wide range of cognitive and non-cognitive skills in health-related decisions. HL includes five domains: navigate/access, understand, communicate, evaluate, and use of health information and services. Currently, no tool accurately captures and measures HL in adult patients with asthma and COPD, while utilizing all 5-HL domains.

Objective

Develop a comprehensive functional-based measurement tool for adult asthma and/or COPD patients, while assessing HL on routine actions required to manage their chronic respiratory condition(s).

Methods

We developed our HL tool based on a conceptualization of the link between HL and asthma and COPD management, during needs assessment stage including; a systematic review, which was followed by patient-oriented focus groups, and key-informant and respirologist interviews. Preliminary face and content validation were obtained by patients’ and health professionals’ input prior to the pretesting stage. The needs assessment information enabled us to develop passages in scenario-format and corresponding items to assess HL core domains, in addition to numeracy skills, across nine self-management topics: peak flow meters, prednisone use, pulmonary rehabilitation, action plans, flu shots, inhaler technique, lifestyle (nutrition and exercise), trigger control, and map navigation. The tool was pretested with asthma and COPD patients to assess its relevance, clarity, and difficulty.

Results

Our systematic review identified the deficiencies of existing HL tools that assessed the HL skills of asthma and COPD patients. The patient-oriented focus groups (n=93) enabled us to identify self-management topics and develop items for our proposed HL tool, which were enriched by input from 45 key informants (eg, policy makers, clinicians, etc.) and 17 respiratory physicians. Preliminary pretesting with a new cohort of participants (36 asthma and COPD patients and 39 key informants) aided in the refinement and finalized our tool. The modified tool included passages and corresponding items related to asthma and COPD management was pretested with 75 asthma/COPD patients who completed the questionnaire and provided their feedback on the clarity, relevance, and difficulty of the tool. The main barrier to self-management pertained to “communication” skills. The flu shot was the most relevant topic (91.2%), while map navigation was the least relevant (63.9%). Action plans were the most difficult topic, where only 55% knew when to utilize their action plans. Numeracy items challenged COPD patients the most.

Conclusion

We summarized findings from the development and preliminary testing stages of a new asthma/COPD HL tool. This tool will now be validated with a new cohort of patients.

Practice Implications

Knowledge gained in this study has been applied to the final version of the tool, which is currently being validated.

Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives

Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.

Treatment Adherence in Young Children with Asthma

Treatment nonadherence in young children with asthma involves multiple factors and should be viewed within an ecological framework. Few interventions have targeted multiple bidirectional factors, however, and little research has examined which interventions may be most appropriate for young children. Additional research is needed to identify essential intervention components, and to determine how to sustain such interventions in at-risk communities. Pediatric psychologists, with training in psychosocial intervention, screening, and primary prevention models, may be uniquely equipped to partner with communities and medical settings to develop and sustain targeted interventions for young children with asthma.

Factors influencing self-management in Parkinson's disease: A cross-sectional study

This study aimed to identify factors influencing self-management in patients with Parkinson's disease (PD) based on social cognitive theory. A cross-sectional design was used; data were collected at three tertiary medical centers in Korea from a convenience sample of 356 PD patients. Higher self-management scores were associated with higher education level, having a religion, and higher family income. Self-management score was positively correlated with activities of daily living, self-efficacy, and social support, and negatively correlated with non-motor symptoms. Hierarchical regression analysis revealed that demographic factors and non-motor symptoms explained 26.2% of the variance in self-management in PD. The explanatory power increased by 7.5% when self-efficacy was added, and by 6.7% when social support was added. Assessment of self-management in patients with PD should consider self-efficacy and social support, along with demographic factors and non-motor symptoms. Self-management programs that reflect these factors may be useful for improving self-management in PD patients.

Development and preliminary results of an Electronic Medical Record (EMR)-integrated smartphone telemedicine program to deliver asthma care remotely

INTRODUCTION

Technology-based interventions that can function within real-world practice and improve outcomes without increasing provider burden are needed, yet few successfully cross the research-to-practice divide. This paper describes the process of developing a clinically integrated smartphone-telemedicine program for adults with asthma and results from proof-of-concept testing.

METHODS

We used a contextually grounded intervention development approach and May's implementation theory to design the intervention, with emphasis on systems capabilities and stakeholder needs. The intervention incorporated symptom monitoring by smartphone, smartphone telemedicine visits and self-management training with a nurse, and clinical decision-support software, which provided automated calculations of asthma severity, control and step-wise therapy. Seven adults (aged 18-40 y) engaged in a 3-month beta-test. Asthma outcomes (control, quality of life, FEV₁) and healthcare utilisation patterns were measured at baseline and end-of-study.

RESULTS

Each participant averaged four telemedicine visits (94% patient satisfaction). All participants had uncontrolled asthma at baseline; end-of-study 5/7 classified as well-controlled. Mean asthma control improved 1.55 points (CI = 0.59-2.51); quality of life improved 1.91 points (CI = 0.50-3.31), FEV₁ percent predicted increased 14.86% (CI = -3.09-32.80): effect sizes of d = 1.16, 1.09, and 0.96, respectively. Preventive healthcare utilisation increased significantly (1.86 visits/year vs. 0.28/year prior, CI 0.67-2.47) as did prescriptions for controller medications (9.29 prescriptions/year vs. 1.57 prescriptions/year, CI 4.85-10.58).

DISCUSSION

Smartphone telemedicine may be an effective means to improve outcomes and deliver asthma care remotely. However, careful attention to systems capabilities and stakeholder acceptability is needed to ensure successful integration with practice.Clinical Trials registration #: NCT03648203.

A Mixed-methods Study Examining Inhaler Carry and Use among Children at School

Objective: Asthma self-management depends partly on access to inhalers; for children, this includes independent inhaler carry and use at school ("self-carry"). Although laws and policies support self-carry, little is known about practices within schools. This study aimed to identify factors associated with inhaler self-carry among children and examine barriers and facilitators to self-carry.Methods: This mixed-methods observational study included child-parent dyads and nurses from four Chicago schools. Children and parents answered questions about asthma care and morbidity, confidence in self-carry skills, and facilitators and barriers to self-carry. Nurses reported asthma documentation on file and their confidence in children's self-carry skills. Analysis utilized logistic regression. Thematic analysis was performed for open-ended questions.Results: Of 65 children enrolled (mean = 10.66 years), 45 (69.2%) reported having quick-relief medication at school, primarily inhalers, and 35 (53.8%) reported self-carry. Inhaler self-carry was associated with controller medication use and parent confidence in child's self-carry skills. Children and parents identified several facilitators to self-carry: child's asthma knowledge, inhaler characteristics, and need for easy inhaler access. Barriers included child's limited understanding of asthma and inhalers, perception that inhaler is not needed, and limited inhaler access. Children also emphasized social relationships as facilitators and barriers, while parents described children's responsibility as a facilitator and inconsistent policy implementation as a barrier.Conclusions: Efforts to improve inhaler self-carry at school should focus on educating children about asthma and inhaler use, creating supportive environments for self-carry among peers and teachers, and fostering consistent implementation and communication about asthma policy among schools and families.

Barriers and Facilitators to Implementing Evidence in African Health Care: A Content Analysis With Implications for Action

BACKGROUND

Culture- and context-specific issues in African countries such as those related to language, resources, technology, infrastructure and access to available research may confound evidence implementation efforts. Understanding the factors that support or inhibit the implementation of strategies aimed at improving care and health outcomes specific to their context is important.

AIMS

The aim of this study was to determine barriers and facilitators to evidence implementation in African healthcare settings, based on implementation projects undertaken as part of the Joanna Briggs Institute (JBI) Clinical Fellowship program.

METHODS

Reports of implementation projects conducted in Africa were obtained from the JBI database and printed monographs associated with the fellowship program. A purpose-built data extraction form was used to collect data from individual reports. Data were analysed using content analysis.

RESULTS

Eleven published and nine unpublished implementation reports were reviewed. The most frequently reported barriers to evidence implementation operate at the health organization or health practitioner level. Health organization-level barriers relate to human resources, material resources and policy issues. Health practitioner-level barriers relate to practitioners' knowledge and skills around evidence-based practice, and attitudes to change. Barriers at the government and consumer levels were uncommon. Only a few facilitators were identified and were related to health practitioners' attitudes or support from the organization's management.

LINKING EVIDENCE TO ACTION

The study identified a core set of barriers and facilitators in African healthcare settings, which are common to other low- and middle-income countries. These can be used to develop a method by which implementation programs can systematically undertake barrier or facilitator analysis. Future research should aim to develop a process by which these barriers and facilitators can be prioritised so that a structured decision support procedure can be established.

Asthma self-management education in persons with work-related asthma - United States, 2012-2014

Objective: According to the National Asthma Education and Prevention Program (NAEPP), self-management education is an integral component of effective asthma care and should be offered to every patient with asthma. To estimate the proportion of persons with work-related asthma (WRA) who received asthma self-management education.Methods: A cross-sectional analysis of 2012-2014 Behavioral Risk Factor Surveillance System Asthma Call-back Survey data was conducted among ever-employed adults (≥18 years) with current asthma from 31 states and the District of Columbia.Results: Adults with WRA were significantly more likely than those with non-WRA to have ever taken a course to manage their asthma (15.7% versus 6.5%; PR = 2.1), been given an asthma action plan (43.5% versus 26.1%; PR = 1.7), shown how to use an inhaler (97.2% versus 95.8%; PR = 1.0), taught how to recognize early symptoms of an asthma episode (79.4% versus 64.1%; PR = 1.2), taught what to do during an asthma episode (86.4% versus 76.3%; PR = 1.1), taught how to use a peak flow meter to adjust daily medications (57.9% versus 41.7%; PR = 1.3), and advised to change things in home, school, or work (56.9% versus 30.4%; PR = 2.0). Moreover, targets for corresponding Healthy People 2020 respiratory disease objectives were met only among adults with WRA.Conclusions: Although adults with WRA were more likely to have received asthma self-management education, results suggest missed opportunities to provide asthma self-management education. Every healthcare visit should be used as an opportunity to discuss asthma self-management.

Factors Associated with Parents' Adherence to Different Types of Exercises in Home Programs for Children with Disabilities

There is a lack of knowledge with regard to the adherence to different types of exercises prescribed for children with disabilities. The aim was to examine parents' adherence to prescriptions of different types of home exercises; to identify associated factors related to the parents, the children and the environment, and to assess the relative influence of the behaviour of health professionals. Parents (393) were recruited from 18 early intervention centres. A cross-sectional survey using a self-reported questionnaire was used to examine whether three types of exercises ("flexibility exercises", "neuromotor development training" and "body mechanics and postural stabilisation") were prescribed in their home programs; if the child had received exercises according to a prescription; and items related to the parents, child, environment, and health professionals. The adherence rates were different among the types of exercises. Parents with low perception of barriers and high self-efficacy had a higher adherence to neuromotor development training and postural stabilization, whereas parents with a high level of knowledge increased their odds of adherence to flexibility exercises. Health professionals' behaviour had a distinct influence on the adherence to different exercises. This study suggests the need to specifically consider the types of exercises prescribed in the management of adherence to home programs.

Effective Engagement of Adolescent Asthma Patients With Mobile Health-Supporting Medication Adherence

Background

Mobile health (mHealth) apps have the potential to support patients’ medication use and are therefore increasingly used. Apps with broad functionality are suggested to be more effective; however, not much is known about the actual use of different functionalities and the effective engagement.

Objective

The aim of this study was to explore the use and the effective engagement of adolescents (aged 12 to 18 years) with the Adolescent Adherence Patient Tool (ADAPT).

Methods

The ADAPT intervention consisted of an app for patients, which was connected to a management system for their pharmacist. The aim of the ADAPT intervention was to improve medication adherence and, therefore, the app contained multiple functionalities: questionnaires to monitor symptoms and adherence, medication reminders, short movies, pharmacist chat, and peer chat. For this study, data of the ADAPT study and a cluster randomized controlled trial were used. Adolescents with asthma had 6 months’ access to the ADAPT intervention, and all app usage was securely registered in a log file.

Results

In total, 86 adolescents (mean age 15.0, SD 2.0 years) used the ADAPT app 17 times (range 1-113) per person. Females used the app more often than males (P=.01) and for a longer period of time (P=.03). On average, 3 different functionalities were used, and 13% of the adolescents used all functionalities of the app. The questionnaires to monitor symptoms and adherence were used by most adolescents. The total app use did not affect adherence; however, activity in the pharmacist chat positively affected medication adherence (P=.03), in particular, if patients sent messages to their pharmacist (P=.01).

Conclusions

mHealth apps for adolescents with asthma should contain different functionalities to serve the diverging needs and preferences of individual patients. Suggested key functionalities to promote use and effectiveness in adolescents with asthma are questionnaires to monitor symptoms and a health care provider chat.

Perceptions of complementary/alternative medicine use and influence on evidence-based asthma medicine adherence in Malaysian children

Complementary and alternative medicine (CAM) is widely used especially in Asia including for childhood asthma. The use of CAM could influence adherence to evidence-based (E-B) medicine. We explored the views of carers of Malaysian children with asthma regarding the use of CAM for childhood asthma, and its relationship with self-reported adherence to E-B medicine. We used a screening questionnaire to identify children diagnosed with asthma from seven suburban primary schools in Malaysia. Informed consent was obtained prior to the interviews. We conducted the interviews using a semi-structured topic guide in participants' preferred language (Malay, Mandarin, or Tamil). All interviews were audio-recorded, transcribed verbatim and coded using Nvivo. Analysis was performed thematically, informed by the Necessity-Concerns Framework. A total of 46 carers (16 Malays, 21 Indians, 9 Chinese) contributed to 12 focus groups and one individual interview. We categorised participants' as 'Non-CAM'; 'CAM'; or 'combination' user. Cultural practices and beliefs in the efficacy of CAM resulted in widespread use of CAM. Most carers used CAM as 'complementary' to E-B medicine. Concerns about dependence on or side effects of E-B treatment influenced carers' decisions to rely on CAM as an 'alternative', with an important minority of accounts describing potentially harmful CAM-use. Healthcare professionals should discuss beliefs about the necessity for and concerns about use of both E-B medicine and CAM, and provide balanced information about effectiveness and safety. The aim is to improve adherence to regular E-B preventer medication and prevent delays in seeking medical advice and harmful practices associated with CAM.

Guided asthma self-management or patient self-adjustment? Using patients' narratives to better understand adherence to asthma treatment

PURPOSE

The purpose of this study was to better understand patients' perspective of asthma self-management by focusing on the sociocultural and medical context shaping patients' illness representations and individual decisions.

PATIENTS AND METHODS

We conducted a secondary analysis of semi-structured interviews carried out as part of a multicentered collective qualitative case study. In total, 24 patients, aged 2-76 years with a confirmed diagnosis of asthma (or were parents of a child), who renewed the prescription for inhaled corticosteroids in the past year, participated in this study. The thematic analysis focused on asthma-related events and experiences reported by the patients. Consistent with narrative inquiry, similar patterns were grouped together, and three vignettes representing the different realities experienced by the patients were created.

RESULTS

The comparison of experiences and events reported by the patients suggested that patients' perceptions and beliefs regarding asthma and treatment goals influenced their self-management-related behaviors. More specifically, the medical context in which the patients were followed (ie, frame in which the medical encounter takes place, medical recommendations provided) contributed to shape their understanding of the disease and the associated treatment goals. In turn, a patient's perception of the disease and the treatment goals influenced asthma self-management behaviors related to environmental control, lifestyle habits, and medication intake.

CONCLUSION

Current medical recommendations regarding asthma self-management highlight the importance of the physicians' guidance through the provision of a detailed written action plan and asthma education. These data suggest that while physicians contribute to shaping patients' beliefs and perceptions about the disease and treatment goals, patients tend to listen to their own experience and manage the disease accordingly. Thus, a medical encounter between the patient and the physician, aiming at enhancing a meaningful conversation about the disease, may lead the patient to approach the disease in a more effective manner, which goes beyond taking preventative paths to avoid symptoms.

Non-pharmacological management of adult asthma in Australia: cross-sectional analysis of a population-based cohort study

Aim: To identify the level of non-pharmacological care received by middle-aged adults with current asthma in Australia and to identify its association with clinical measures. Methods: The Tasmanian Longitudinal Health Study (TAHS) is a population-based cohort first studied in 1968 (n = 8583). In 2010, when participants were aged 49 years, a stratified sample enriched for asthma and bronchitis underwent clinical assessments including respiratory questionnaires and lung function testing (n = 836). Current asthma was defined as self-reported asthma symptoms and/or healthcare utilization in the last 12 months. Multivariable linear regression and log-binomial models were used to assess the relevant associations. Results: Of the entire TAHS cohort, 15.6% (95% CI 13.4-18.2%) had current asthma. Of these, 37.9% (95% CI 30.5-45.9%) had seen a general practitioner for their asthma and 16.5% (95% CI 11.5-23.1%) had discussed their asthma with a pharmacist in the last 12 months. Written asthma action plans (AAPs) were reported by 17.9% (95% CI 12.9-23.2%), verbal AAPs by 53.8% (95% CI 45.9-61.6%) and doctor-assessments of inhaler technique by 42.7% (95% CI 35.2-50.5%). Adults with asthma of greater severity were more likely to have received verbal AAPs (p-trend =0.02). In contrast, adults with lower spirometry were more likely to have received verbal AAPs (p = 0.04), written AAPs (p = 0.001) and education on inhaler technique (p = 0.04). Conclusion: Despite an established evidence base and recommendations in local and international guidelines, non-pharmacological asthma management remains sub-optimal in the middle-aged adult asthma population.

Barriers and Facilitators to Asthma Care After Hospitalization as Reported by Caregivers, Health Providers, and School Nurses

OBJECTIVES

To develop a comprehensive understanding of the barriers and/or facilitators for asthma management for the health professionals and caregivers of children with >1 hospitalization.

METHODS

Individual interviews were conducted with family caregivers and health professionals. Focus groups were conducted with school nurses. The interview and focus group guide were used to probe for barriers and facilitators of asthma management. Interviews were recorded, transcribed, and coded by using qualitative software. Themes were identified by using content analysis in the interviews and descriptive qualitative analysis in the focus groups.

RESULTS

Caregivers (n = 10), asthma educators (n = 4), physicians (n = 4), and a payer (n = 1) were individually interviewed. School nurses were interviewed via a focus group (n = 10). Children had a median age of 7 years, mean length of stay of 1.9 days, and 56% had a previous hospitalization in the previous 12 months. The "gaps in asthma knowledge" theme (which includes an inadequate understanding of asthma chronicity, activity restrictions, and management with controller medications) emerged as a theme for both caregivers and health professionals but with different health beliefs. School nurses reinforced the difficulty they have in managing children who have asthma in schools, and they identified using the asthma action plan as a facilitator.

CONCLUSIONS

Caregivers and health professionals have different health beliefs about asthma knowledge, which raises challenges in the care of a child who has asthma. In addition, school nurses highlight specific barriers that are focused on medication use in schools. A comprehensive understanding of the barriers and facilitators of asthma management that families experience after hospital discharge is crucial to design better efforts to support families.

How do the experiences and beliefs of adults and children with heterozygous familial hypercholesterolaemia influence their adherence to treatment? A systematic review of qualitative evidence protocol

BACKGROUND

Heterozygous familial hypercholesterolaemia (FH) is a genetic disorder characterised by elevated levels of low density lipoprotein (LDL) cholesterol from birth, estimated to affect 1 in 250 of the UK population. Left untreated, FH substantially increases an individual's risk of premature coronary heart disease (CHD) and associated mortality. This risk can be minimised with timely diagnosis and successful treatment with medication and lifestyle changes, as advocated in national and international guidelines. Despite these recommendations, the limited research available suggests adherence to treatment may be sub-optimal. This review will identify and synthesise the available qualitative research regarding the experiences and beliefs of adults and children with FH in relation to their condition and its treatment, and the influence of these upon treatment adherence.

METHODS

The following electronic databases will be searched from their inception: Cochrane library, MEDLINE, Embase, PsycINFO (via OVID) and CINAHL. Studies available in English and reporting primary qualitative data will be included. Database searching will be supplemented with searches in relevant specialist websites. The references of identified papers will also be hand searched. Two reviewers will independently screen titles and abstracts of identified studies, with full texts of potentially relevant papers retrieved for review against pre-defined inclusion and exclusion criteria. The Critical Appraisal Skills Programme (CASP) Qualitative Research checklist will be used to assess quality of the included studies, and the results will be taken into consideration when reporting the findings. A data extraction tool will be created for use in this review to extract study findings relevant to the review questions. A thematic synthesis approach will be taken to analyse the results.

DISCUSSION

Adherence to treatment recommendations is crucial for the successful management of FH and subsequent decrease in risk of CHD later in life. Common identified themes could provide an understanding of the beliefs and experiences which influence adherence to treatment recommendations and provide an insight into perceived barriers and facilitators. The findings are intended to be used in the development of future interventions or guidelines regarding treatment of children and adults with FH.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42018085946.

Barriers and facilitators to self-management of asthma in adolescents: An interview study to inform development of a novel intervention

BACKGROUND AND OBJECTIVE

Despite literature that spans twenty years describing the barriers to asthma self-management in adolescents, successful, clinically based interventions to address this important issue are lacking. Given the limitations of some of the previous studies, we conducted a study that aimed to gain a broader insight into barriers and facilitators to self-management of asthma by adolescents, not just adherence to treatment, and triangulated their views with those of their parents and healthcare professionals.

METHODS

Focus groups and interviews were conducted separately for 28 adolescents with asthma aged 12-18 years, 14 healthcare professionals and 12 parents. Focus groups and interviews were audio-recorded, and transcripts from each participant group were analysed separately using inductive thematic analysis. We triangulated the three perspectives by comparing themes that had emerged from each analysis.

RESULTS

Adolescents', parents' and healthcare professionals' views were summarized into ten related themes that included forgetting and routines, knowledge, embarrassment and confidence, communication with healthcare professionals, triggers, support at school, apathy and taking responsibility. We found that adolescents, parents and healthcare professionals raised similar barriers and facilitators to self-management and our results provide further validation for previous studies.

CONCLUSION AND CLINICAL RELEVANCE

Our study highlights that healthcare professionals may need to consider a range of psychological and contextual issues influencing adolescents' ability to effectively self-manage their asthma, in particular, how they implement treatment routines and the understanding that adolescents have of their condition and treatments. Crucially, healthcare professionals need to consider how this information is communicated and ensure they facilitate open, inclusive, two-way consultations. From this more comprehensive understanding, we have developed interventional strategies that healthcare professionals can utilize to empower adolescents to improve their asthma self-management.