Medical compliance in juvenile rheumatoid arthritis. Problems and perspectives

Adherence to exercise therapy among children and adolescents with Juvenile idiopathic arthritis: a scoping review

PURPOSE

To identify parameters and measurement methods of exercise therapy adherence, as well as barriers and facilitators affecting adherence among children and adolescents with juvenile idiopathic arthritis (JIA).

METHODS

Studies were eligible for inclusion if patients were 0-18 years of age, had JIA, and the focus of the research was on exercise therapy patterns, measurement/parameters of exercise adherence, and barriers/facilitators for exercise adherence. Two reviewers independently identified and categorized the barriers and facilitators to exercise therapy adherence using the International Classification of Functioning, Disability, and Health (ICF).

RESULTS

Twenty articles were included in this review. Among patients with JIA, 29%-99% adhered to exercise therapy. The most commonly measured parameters of adherence were session completion and behavior component, with a self-report log serving as the most common means of assessment. Time pressure, symptoms related to JIA, lack of enjoyment, and insufficient motivation were the main barriers. Facilitators were commonly identified as adequate motivation, effective symptoms management, and social support.

CONCLUSIONS

Future interventions should consider the identified factors to promote exercise engagement in children and adolescents with JIA. Strategies for promoting exercise adherence in children and adolescents with JIA is needed.

Barriers to Adherence in Juvenile Idiopathic Arthritis: A Multicenter Collaborative Experience and Preliminary Results

OBJECTIVE

Nonadherence is currently an underrecognized and potentially modifiable obstacle to care in juvenile idiopathic arthritis (JIA). The purpose of our study was to design and implement a standardized approach to identifying adherence barriers for youth with JIA across 7 pediatric rheumatology clinics through the Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) and to assess the frequency of adherence barriers in patients and their caregivers across treatment modalities.

METHODS

An iterative process using coproduction among parents and providers of patients with JIA was used to design the Barriers Assessment Tool to screen for adherence barriers across 4 treatment modalities (i.e., oral medications, injectable medications, infusions, and physical/occupational therapy). This tool was implemented in 7 rheumatology clinics across the United States and patient responses were collected for analysis.

RESULTS

Data were collected from 578 parents and 99 patients (n = 44 parent-child dyads). Seventy-seven percent (n = 444) of caregivers and 70% (n = 69) of patients reported at least 1 adherence barrier across all treatment components. The most commonly reported adherence barriers included worry about future consequences of therapy, pain, forgetting, side effects, and embarrassment related to the therapy. There was no significant difference between endorsement of barriers between parents and adolescents.

CONCLUSION

Implementing a standardized tool assessing adherence barriers in the JIA population across multiple clinical settings is feasible. Systematic screening sheds light on the factors that make adherence difficult in JIA and identifies targets for future adherence interventions in clinical practice.

Quality of life and trust among young people with narcolepsy and their families, after the Pandemrix® vaccination: protocol for a case-control study

Background

The extensive vaccination programme against swine flu resulted in an increased incidence of narcolepsy among children and adolescents. There is a need to explore if these young persons’ experiences have affected their trust in healthcare, their willingness to participate in future prevention programmes, and their contacts with the healthcare system. The overall aim is to identify factors important for the life-situation of children and adolescents with narcolepsy and their families, and factors that correlate with trust in healthcare.

Methods/design

Data will be collected via questionnaires from all available children with narcolepsy following the vaccination and their families, as well as a control group of children with diabetes and their families. Longitudinal descriptive interviews will also be conducted with a selection of 20–25 children and their families. Techniques from media research will be used for Internet-based data collection and analysis of information relating to narcolepsy from social media.

Discussion

This project will use the situation of young persons with narcolepsy after the swine flu vaccination as a case to build a model that can be used in situations where trust in healthcare is essential. This model will be based on findings from the included studies on how trust is influenced by support, quality of life, burden of disease, impact on family, and use of social media. The model developed in this project will be beneficial in future situations where trust in healthcare is essential, such as new pandemic outbreaks but also for “everyday” adherence to health advice.

Development of a Children's Trust in General Physicians Scale

BACKGROUND

Researchers have developed scales assessing adults' trust beliefs in physicians and found that those are associated with measures of health behaviour and physical health. The purpose of the research was to develop a Children's Trust in General Physicians Scale (CTGPS) and examine its relation to health behaviour: adherence to medical regimes.

METHODS

The participants were 128 children (68 girls and 60 boys) in Study 1 and 198 children (105 girls and 93 boys) in Study 2 who attended years 5 and 6 of elementary school in UK (mean ages = 10 years and 10 months and 10 years and 7 months respectively). The children completed the nine-item CTGPS and reported their trust in doctors and (in Study 2) adherence to medical regimes. Parents also reported those behaviours.

RESULTS

Principal components analysis and confirmatory factor analysis of the CTGPS yielded the expected three factors: Honesty, Emotional and Reliability. The CTGPS had acceptable internal consistency and, as evidence for its validity, was associated with reported trust in doctors. The results from Study 2 confirmed that the CTGPS was associated with adherence to medical regimes.

CONCLUSION

A CTGPS was developed that is associated with adherence to medical regimes.

Improving adherence to medical regimens for juvenile rheumatoid arthritis

Poor adherence to medical regimens can compromise the efficacy of treatments for children and adolescents with juvenile rheumatoid arthritis (JRA). The purpose of this review is to describe medical regimens for the treatment of JRA and the rates of adherence to these regimens. We also summarize and critically the few research studies aimed at improving adherence to regimens for JRA. Finally, we summarize strategies for enhancing adherence in clinical practice.

Perceived adherence to prescribed treatment in juvenile idiopathic arthritis over a one-year period

OBJECTIVE

To document perceived adherence to treatment (taking medications and performing exercises) in patients with juvenile idiopathic arthritis (JIA) over a 1-year period and to identify related factors.

METHODS

We surveyed parents of patients with JIA at the Montreal Children's Hospital and British Columbia's Children's Hospital in Vancouver. Parents were asked to respond to a series of questionnaires every 3 months over a 12-month period. Perceived adherence was evaluated on a 100-mm visual analog scale (VAS) in the Parent Adherence Report Questionnaire (PARQ). Parental coping, distress, child function, disease severity and duration, perceived helpfulness of treatment, problems encountered, and sociodemographic data were also assessed.

RESULTS

The mean age of our sample of 175 children was 10.2 years; mean age at diagnosis was 6.1 years and mean disease duration was 4.1 years. Perceived adherence to medications was consistently high, with average adherence at baseline, 3, 6, 9, and 12 months being 86.1, 91.7, 90.4, 92.0, and 88.8, respectively, on the PARQ VAS. Perceived adherence to exercise was lower but remained steady, with corresponding means of 54.5, 64.1, 61.2, 63.0, and 54.3, respectively. Using generalized estimating equation analysis, factors associated with higher perceived adherence to medications included perceived helpfulness of medications and lower disease severity; those associated with higher perceived adherence to exercise were younger age of the child, child involvement in responsibility for treatment, and higher perceived helpfulness of the treatment.

CONCLUSION

Belief in helpfulness of treatment is associated with higher parental perceived adherence to treatment.

Caregiver recall of treatment recommendations in juvenile idiopathic arthritis

OBJECTIVE

Health care providers in juvenile idiopathic arthritis (JIA) might refer to caregivers' self-report of children's treatment-related behaviors to assist in clinical decisions. However, caregivers may believe that they are adhering to treatment even though they have a different understanding of recommendations than that intended by the medical team. We examined whether caregiver recall of children's JIA treatment matched actual recommendations at baseline and 3, 6, 9, and 12 months.

METHODS

A total of 235 primary caregivers were recruited from rheumatology clinics at 2 pediatric university-based teaching hospitals in Canada. Using the Parent Adherence Report Questionnaire, caregivers indicated whether their child was prescribed medications and/or exercises. Medical charts were reviewed to determine the prescribed treatment. Level of agreement between both sets of data was then examined.

RESULTS

A total of 175 caregivers provided complete data. Mean age of the children was 10.2 years (68.6% girls); 44.6% were diagnosed with oligoarthritis. Kappa coefficients for medication represented substantial to almost perfect agreement beyond chance, with better levels of agreement at 12 months (kappa = 0.81, 95% confidence interval [95% CI] 0.68, 0.94) than at baseline (kappa = 0.61, 95% CI 0.47, 0.76). Kappa coefficients for exercise represented slight to moderate agreement beyond chance, with better agreement at 12 months (kappa = 0.44, 95% CI 0.24, 0.63) than at baseline (kappa = 0.27, 95% CI 0.08, 0.47).

CONCLUSION

Weaker agreement for the exercise regimen raises concern that caregivers may pay less attention to exercise recommendations or that these recommendations may not be easily understood.

Management of adherence and chronic rheumatic disease in children and adolescents

Medical treatment regimens for pediatric rheumatic diseases are complex, have delayed beneficial effects, and require consistent adherence over a long period of time. All of these factors place patients at risk for non-adherence that can compromise the benefits of treatment and the long-term health and quality of life for patients. This chapter provides a definition of adherence and reviews the prevalence of non-adherence to regimens for pediatric rheumatic diseases. It also describes various methods for assessing adherence, including assays, observation, electronic monitoring, pill counts, and provider or patient ratings of adherence. Studies which identify risk factors for non-adherence are also reviewed, with suggestions on how these risk factors might be addressed. The final section reviews the few studies that have reported on efforts to improve adherence to regimens for pediatric rheumatic diseases and offers strategies for providers to promote adherence with their patients.

Comparison between children with juvenile idiopathic arthritis and their parents concerning perceived treatment adherence

OBJECTIVE

Adherence to treatment in juvenile idiopathic arthritis (JIA) may be associated with better outcomes. Clinicians must be aware of possible divergence between parents and children regarding adherence, in order to gain a better understanding of adherence and factors associated with it. The objective was to determine the level of agreement between children with JIA and their parents concerning perception of the child's adherence to the treatment regimen (for both medications and exercises).

METHODS

Fifty patients and their parents, who attended the JIA clinic at the Montreal Children's Hospital, completed the Child Adherence Report Questionnaire and the Parent Adherence Report Questionnaire. Paired t-tests were used to compare parents' and children's scores for adherence questions and agreements were analyzed by intraclass correlation coefficients (ICCs).

RESULTS

Parents reported that their children showed more negative reactions to taking medication and doing exercises, more helpfulness from the medication, and more difficulty to carry out the exercise program than their children reported. ICCs (95% confidence interval) for medications and exercises were, respectively, 0.32 (0.04, 0.56) and 0.77 (0.61, 0.87) for overall adherence, 0.33 (0.05, 0.57) and 0.39 (0.09, 0.62) for perceived difficulty to following treatment, and 0.37 (0.09, 0.60) and 0.45 (0.17, 0.67) for how often children had negative reactions following treatment. Levels of agreement for perceived helpfulness of treatments were quite low.

CONCLUSION

Agreement between parents and children concerning adherence was at best moderate, and generally better for the exercise program than for prescribed medications.

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.

Family-level coping in juvenile rheumatoid arthritis: assessing the utility of a quantitative family interview

OBJECTIVE

To explore the viability of a quantitative family interview to describe family-level coping strategies used to deal with juvenile rheumatoid arthritis (JRA)-related stressors for early and late adolescents.

METHOD

A structured interview protocol with 30 adolescents with JRA and family members assessed ways JRA disrupts or changes family functioning. Emotional reactions, sequential phases of family response, and treatment adherence were discussed. Interviews were coded for family-level coping. To assess adjustment, family members completed the Youth Self Report and the Family Environment Scale. The pediatric rheumatologist provided medical information.

RESULTS

The family interview produced both quantitative and qualitative data. Families reported multiple JRA-related stressors (mean 6.6). For many adolescents, treatment adherence was problematic. Families used all 3 types of coping strategies (appraisal-, problem-, and emotion-focused) to varying degrees. Problem-focused approaches were most commonly used and included seeking support (used by 73% of families), self-reliance (70%), and family coordination (70%) for dealing with specific problems, and seeking information about JRA (67%). Emotion-focused approaches, such as impulsive outbursts and diminished awareness of others' feelings, were associated with problematic adjustment. Few differences were found between the families of early and late adolescents.

CONCLUSION

The quantitative family interview has the potential to be a useful tool in documenting JRA-related stressors, family-level coping processes, and how family-level coping is associated with treatment adherence and psychosocial adjustment.

An educational needs assessment of children with juvenile rheumatoid arthritis

OBJECTIVE

Our objective is to describe the use of the PRECEDE model (predisposing, reinforcing, and enabling causes in educational diagnosis and evaluation) to organize needs assessment data in order to define self-management behaviors and plan an educational intervention for children with juvenile rheumatoid arthritis (JRA) and their families.

METHODS

Analysis was done of needs assessment data collected from several sources: 1) literature review, 2) survey of parents of 51 children with JRA, 3) group interview of seven parents of children with JRA, 4) results of pilot programs, and 5) clinical experience of an interdisciplinary pediatric rheumatology team.

RESULTS

Two sets of interrelated behavioral factors were identified through the needs assessment: 1) those related to managing the school environment to facilitate optimal participation and to minimize school-related disability, and 2) those related to treating pain and stiffness, intervening in the disease process, and preserving joint function.

CONCLUSION

Both of these sets of behavioral factors may be related to the optimization of children's mobility, joint function, and autonomy of activities of daily living and should be targets of an educational intervention.

Compliance with treatment regimens for pediatric rheumatic diseases

Children with pediatric rheumatic diseases (PRDs) are required to comply with long-term treatment regimens that may not have immediate beneficial effects or may be required primarily to prevent further morbidity. As with other chronic disease regimens, compliance can be a significant problem that interferes with treatment efficacy and adequate clinical outcomes. This paper reviews (1) the prevalence and types of compliance problems in the management of PRDs; (2) patient/family, disease, and regimen factors that may be associated with treatment noncompliance; and (3) strategies for improving compliance with regimens for PRDs.