The Influence of Informal Caregivers on Adherence in COPD Patients

Perceived Spousal Support and Activities of Daily Living in Individuals With COPD

BACKGROUND

The relationship between perceived spousal support and activities of daily living in patients with chronic obstructive pulmonary disease (COPD) is unclear.

PURPOSE

The aim of this study was to explore the relationship between spousal support perceived by those with COPD and their activities of daily living.

METHODS

This study was a cross-sectional and descriptive study. Data collection was conducted between September 2022 and April 2023. A Data Gathering Form, the Spousal Support Scale, and the London Chest Activity of Daily Living Scale were used to collect data. A total of 132 adults were included in this study.

RESULTS

The mean (SD) scores of individuals with COPD for perceived spousal support and activities of daily living were 62.40 (14.66) and 32.91 (15.72), respectively. Levels of perceived spousal support and activities of daily living varied according to sex, employment status, admission to the emergency service or hospitalization, use of antidepressants, and the severity of the illness (P < .05). Those with better spousal support felt less dyspnea when performing the activities of daily living (r = -0.205, P < .05).

CONCLUSIONS

Knowing the potential factors affecting perceived spousal support and activities of daily living can provide an opportunity to determine appropriate strategies to increase the level of independence of individuals with COPD. Educational interventions to help spouses understand COPD may help increase spousal support.

Digital Solutions Available to Be Used by Informal Caregivers, Contributing to Medication Adherence: A Scoping Review

Medication adherence is essential for managing chronic diseases and achieving optimal health outcomes. However, this process is often challenging, particularly for patients with complex care needs. Informal caregivers play a pivotal role in supporting medication management, but they may face resource limitations and a lack of necessary support. Digital health tools offer a promising avenue to enhance medication adherence by providing reminders, education, and remote monitoring capabilities. This scoping review aimed to identify and evaluate digital solutions available to informal caregivers for improving medication adherence. A systematic search of PubMed and Web of Science was conducted using relevant keywords. Four studies were included in the review, examining a variety of digital tools including mobile apps, SMS messaging, and wearable devices. These tools demonstrated efficacy in improving medication adherence, managing disease symptoms, and enhancing quality of life for patients and caregivers. Digital health interventions hold the potential to revolutionize medication adherence among chronic disease patients. By empowering informal caregivers, these tools can bridge the gaps in medication management and contribute to better health outcomes. Further research is warranted to optimize the design, implementation, and evaluation of digital interventions for medication adherence.

Methods to assess COPD medications adherence in healthcare databases: a systematic review

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables.

METHOD

We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills.

RESULTS

160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables.

CONCLUSION

Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.

Validity and Reliability of Caregiver Contribution to Self-Care of Chronic Obstructive Pulmonary Disease Inventory and Caregiver Self-Efficacy in Contributing to Self-Care Scale

The study tested the construct validity and reliability of the Caregiver Contribution to Self-Care of Chronic Obstructive Pulmonary Disease (COPD) Inventory and the Caregiver Self-Efficacy in Contributing to Self-Care of COPD Scale. The two instruments were developed by modifying the Self-Care of COPD Inventory and Self-Care Self-Efficacy Scale in COPD into caregiver versions. The psychometric properties were tested in a convenience sample of 261 informal caregivers of COPD patients recruited in Italy in two cross-sectional studies. Structural validity was tested by confirmatory factor analysis, construct validity by posing several hypotheses, and internal consistency through factor score determinacy and global reliability index for multidimensional scales. In confirmatory factor analysis, the caregiver contribution to self-care maintenance, monitoring and management scales, composing the Caregiver Contribution to Self-Care of COPD Inventory, presented good fit indices. Global reliability indices ranged 0.75-0.88. The caregiver self-efficacy scale presented a comparative fit index of 0.96 and a global reliability index of 0.82. The caregiver contribution to self-care and the caregiver self-efficacy scales correlated moderately among themselves and with the patient versions of the scales, and scores were higher with caregiver-oriented dyadic care types and female caregivers. Our study provides evidence of the two instruments' construct validity and internal consistency.

Dyadic Archetypes of Patient Self-Care and Caregiver Contribution to Self-Care in Dyads With Multiple Chronic Conditions: An Observational Study

Self-care of multiple chronic conditions (MCCs) and caregiver contribution to self-care have been theorized as dyadic. However, the different dyadic archetypes are still unknown. This cross-sectional study aimed to identify dyadic archetypes related to how in patient-caregiver dyads manage the patient's MCCs and to describe other ways in which the dyadic archetypes differ. A sample of 340 MCCs patient-caregiver dyads was enrolled in outpatient and community settings. Patients had a mean age of 76.7 (±7.3) years and were mostly female (54.5%). Caregivers had a mean age of 54.6 (±15.1) years and were mostly female (71.5%). Four dyadic archetypes were observed: "autonomous," "compensatory," "balanced," and "complementary" care. Clinical programs should consider the different characteristics of dyads to support self-care.

Up-to-date guidance towards improving medication adherence in patients with chronic obstructive pulmonary disease

INTRODUCTION

Despite efficacious treatment for chronic obstructive pulmonary disease (COPD), medication adherence remains quite poor, with most estimates based on electronic monitoring devices ranging from 20-30%. This degree of nonadherence represents a significant missed opportunity to realize the benefits of treatment of this disease.

AREAS COVERED

In this article, we review research on the prevalence of nonadherence among patients with COPD, the association of nonadherence with health outcomes, barriers to adherence in this patient population, and potential interventions.

EXPERT OPINION

Integrating research into practice involves assessing patients' adherence, identifying modifiable barriers to adherence, open discussion of these barriers with patients, and tailored interventions to address them. These interventions may include treatment of previously unrecognized comorbid disease, providing educational or behavioral interventions, optimizing prescribing strategies, use of adherence aids, or addressing cost and other access barriers. Electronic inhaler monitors are promising interventions for both monitoring and improving adherence. However, remaining concerns about integration into patient care, data management, cost, acceptability, and ethical and privacy issues must be overcome prior to their implementation in clinical practice.

Pharmacotherapies in Older Adults with COPD: Challenges and Opportunities

Older adults have a higher prevalence of chronic obstructive pulmonary disease (COPD), which will likely increase substantially in the coming decades owing to aging populations and increased long-term exposure to risk factors for this disease. COPD in older adults is characterized by low-grade chronic systemic inflammation, known as inflamm-aging. It contributes substantially to age-associated pulmonary changes that are clinically expressed by reduced lung function, poor health status, and limitations in activities of daily living. In addition, inflamm-aging has been associated with the onset of many comorbidities commonly encountered in COPD. Furthermore, physiologic changes that are often seen with aging can influence the optimal treatment of older patients with COPD. Therefore, variables such as pharmacokinetics, pharmacodynamics, polypharmacy, comorbidities, adverse drug responses, drug interactions, method of administration, and social and economic issues that impact nutrition and adherence to therapy must be carefully evaluated when prescribing medication to these patients because each of them alone or together may affect the outcome of treatment. Current COPD medications focus mainly on alleviating COPD-related symptoms, so alternative treatment approaches that target the disease progression are being investigated. Considering the importance of inflamm-aging, new anti-inflammatory molecules are being evaluated, focusing on inhibiting the recruitment and activation of inflammatory cells, blocking mediators of inflammation thought to be important in the recruitment or activation of these inflammatory cells or released by these cells. Potential therapies that may slow the aging processes by acting on cellular senescence, blocking the processes that cause it (senostatics), eliminating senescent cells (senolytics), or targeting the ongoing oxidative stress seen with aging need to be evaluated.

Validity and reliability of the Korean caregiver contribution to self-care chronic illness inventory

The contribution of caregivers to self-care for chronically ill patients is important for improving patient outcomes. The Caregiver Contribution to Self-Care Chronic Illness Inventory (CC-SC-CII) has been used to assess caregivers' contributions to three distinct aspects of self-care (maintenance, monitoring, and management) globally. This study aimed to examine the psychometrics of the Korean version of the CC-SC-CII with 230 family caregivers (mean age = 49.8 years, 70% women) of patients with chronic illness. We demonstrated that the CC-SC-CII-Korean has good reliability with acceptable internal consistency and construct validity for all three factors using confirmatory factor analysis. The CC-SC-CII-Korean is a reliable and valid instrument to measure the contributions of Korean caregivers to the self-care of patients with chronic illnesses.

Relationship between patient functionality impairment and caregiver burden: is there a cut off point for the severe COPD patient?

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients experience a progressive limitation of their functionality accompanying their clinical evolution. Concretely, severe COPD patients usually require the figure of a caregiver. Caregiver burden has yet to be explored in other similar chronic diseases. The objective is to propose a cutoff point in different functional impairment aspects, to predict the presence of caregiver burden.

METHODS

Severe COPD patients were divided into two groups according to the caregiver burden, measured with the Zarit Burden Interview (ZBI). The patients were assessed with the London Chest Activity of Daily Living (LCADL) scale, the Functional Independence Measure (FIM), and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).

RESULTS

70 COPD patients and their caregivers were included in this cross-sectional study. The ROC curve indicated a cutoff point of 19 in the LCADL scale (AUC = 0.722). Dependence in daily life activities had a cutoff point of 123 in the FIM (AUC = 0.776). Social participation in activities of daily living had a cutoff point of 37 in the WHODAS 2.0 (AUC = 0.739).

CONCLUSION

Dyspnea related to functional status, dependence in daily life activities, and social participation in activities of daily living of severe COPD patients can predict caretaker burden.

Self-care in coronary heart disease patient and caregiver dyads (HEARTS-IN-DYADS)-Protocol of a multicenter longitudinal study

Self-care performed by patients and the caregiver contribution to this self-care are essential for improving cardiovascular outcomes; however, so far, no studies have sufficiently investigated this field in Italy. This paper describes a research protocol of a multi-center longitudinal study designed to investigate the self-care of patients affected by coronary heart disease (CHD), the caregiver's contribution to this self-care, the predictors of patient and caregiver self-care, the mediating role of self-efficacy, and the self-care outcomes. Data collection will be performed across seven Italian inpatient settings at baseline and 3 and 6 months from enrollment. Multilevel modeling and actor partner interdependence models will be implemented on a sample of 330 patient-caregiver dyads to adjust for the interdependence of measurements. The study received approval from an ethics committee in Italy and was financed in January 2021 by a grant from the Solidal Foundation in Alessandria. This research will advance the knowledge about the self-care process in CHD. The results will guide research and clinical practice by identifying variables sensitive to educational interventions.

How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology

A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.

Self-Management and Associated Factors among Patients with Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Study

Self-management is critical and essential for controlling non-alcoholic fatty liver disease, delaying progression, and preventing complications. However, information about the self-management characteristics of this population is scarce. This study explores the characteristics and self-management levels and the factors associated with self-management in patients with non-alcoholic fatty liver disease in Korea. A convenience sample of 150 patients diagnosed with non-alcoholic fatty liver disease was recruited from April to November 2019. Demographics and clinical findings were collected, and self-management, self-efficacy, fatigue, and depressive symptoms were assessed using questionnaires. Multiple linear regression analysis was performed to examine the factors associated with self-management. Self-management levels were moderate (Mean = 3.4, SD = 0.61). Self-management differed significantly by age, sex, marital status, occupation, and health education experience. Self-efficacy (β = 0.074, p = 0.020) showed a significant association with self-management, which explained 25.0% of the variance after controlling for age, sex, marital status, health education experience, occupation, controlled attenuation parameter score, and body mass index. Self-efficacy is a critical determinant of self-management among patients with non-alcoholic fatty liver disease. The study findings could assist healthcare professionals in facilitating self-management compliance and developing multidisciplinary team-based interventions for sustainable self-management.

Improving the wellbeing of caregivers of patients with COPD using a home-based pulmonary rehabilitation programme

Objectives

The aim of this study was to evaluate the effects of a home-based pulmonary rehabilitation (PR) programme on anxiety and depressive symptoms, general fatigue and burden in informal caregivers of patients with COPD. We also evaluated the baseline characteristics of both patients and caregivers that contributed to the change in caregiver's outcomes after PR.

Methods

In this retrospective study, patients with COPD were referred to an 8-week home-based PR programme consisting of a weekly supervised 90-min session. Informal caregivers were invited to participate in PR according to the patient's preference and its availability. Caregivers received educational support, behavioural therapies and self-management strategies using the same methods as for patients. Burden, anxiety and depressive symptoms, and general fatigue of caregivers were assessed at baseline and at the end of PR.

Results

241 patients with COPD and 138 (57.3%) caregivers were included. The majority of the caregivers were women (70.5%) and spouses (90.3%) and had at least three comorbidities (57.3%). A large proportion of caregivers showed baseline high burden, anxiety symptoms and abnormal fatigue (40%, 40% and 45%, respectively). Burden, anxiety and depressive symptoms, and general fatigue of informal caregivers were all improved after PR (p<0.05). Long-term oxygen therapy and/or noninvasive ventilation, coronaropathy and/or peripheral arterial disease and a higher baseline modified Medical Research Council Dyspnoea scale score in patients with COPD were associated with a decrease in caregiver's burden after PR.

Conclusion

A large proportion of caregivers of patients with COPD showed anxiety symptoms, fatigue and a high burden. These outcomes were improved by integrating the caregiver into a home-based PR programme.

Patient Self-Care and Caregiver Contribution to Patient Self-Care of Chronic Conditions: What Is Dyadic and What It Is Not

OBJECTIVES

Self-care of chronic conditions involves both patients and their informal caregivers and therefore might be considered as a dyadic phenomenon. Nevertheless, empirical evidence supporting a dyadic construct is unavailable. This study aimed to explore the existence of a dyadic construct in self-care maintenance, monitoring, and management in patients affected by chronic conditions and their informal caregivers.

METHODS

This study used a cross-sectional design. We used the Self-Care of Chronic Illness Inventory and the Caregiver Contribution to Self-Care of Chronic Illness Inventory, which measure patient self-care and informal caregivers' contribution to self-care maintenance, monitoring and management. Exploratory Structural Equation Modeling was performed to verify the existence of dyadic latent constructs in each scale in patients and informal caregivers.

RESULTS

A convenience sample of 493 patients and informal caregivers, with a mean age of 76.47 and 52.76 years, respectively, was studied. In the self-care maintenance scales, 2 correlated factors (r = 0.34, P < .001) were identified, indicating the presence of a dyadic second-order construct. In addition, 2 factors that were not correlated (r = 0.11, P = .064) were identified in the self-care monitoring scales, indicating the absence of a dyadic construct. Finally, we found a 3-factor model in the self-care management scales composed of both patient and caregiver items, indicating a dyadic first-order construct.

CONCLUSIONS

Knowing which care behaviors are dyadic in chronic conditions is important for tailoring interventions to improve self-care. Self-care maintenance and management would benefit from dyadic interventions, while self-care monitoring would not. The results of this study may illuminate future theoretical and scientific developments in dyadic care of chronic illness.

Relationships between social capital, patient empowerment, and self-management of patients undergoing hemodialysis: a cross-sectional study

Background

Hemodialysis is the most common treatment of end-stage renal disease. However, it is associated with a range of symptoms affecting patients’ daily activities and quality of life. Effective self-management has proven crucial for the alleviation of symptoms. According to Social Cognitive Theory, social capital and patient empowerment may be important variables for predicting self-management. To date, few studies have explored the mechanisms underlying these results. The study aimed to verify whether patient empowerment mediated the effect of social capital on the self-management of hemodialysis patients.

Methods

The study was performed with 245 hemodialysis patients from January 2021 to April 2021 in Taiyuan, China. Demographic and clinical characteristics, social capital, patient empowerment, and self-management of patients undergoing hemodialysis were measured with a self-reported questionnaire. Descriptive statistics were used to summarize the participants’ demographic and clinical characteristics, and bootstrapping tests were used to verify whether patient empowerment mediated the association of social capital with self-management in patients undergoing hemodialysis.

Results

Mediation analysis indicated that social capital and patient empowerment significantly predicted self-management. Patient empowerment partially mediated the relationship between social capital and self-management in hemodialysis patients.

Conclusions

The results suggest that hemodialysis patients show relatively poor self-management and that patient empowerment mediates both social capital and self-management. Strategies to mobilize patients’ social networks and help them identify and utilize effective social resources may provide useful information regarding the implementation of optimal health management for their disease.

Informal carers in Sweden - striving for partnership

Purpose

Informal carers have an important role in society through their care and support of their long-term ill relatives. Providing informal care is challenging and can lead to caregiver burden; moreover, many support needs of the carers are not met, leading to confusion, disappointment and frustration. We conducted an interview study to clarify the meaning of support given and received by informal carers to relatives with chronic obstructive pulmonary disease or chronic heart failure.

Methods

We purposively selected and recruited informants via participants in another study, thereby conducting interviews over the phone from June 2016 to May 2017. In total, we conducted 14 interviews with 12 informants. All interviews were transcribed verbatim and the content was analysed using a phenomenological hermeneutical approach.

Result and conclusion

Our comprehensive understanding of the meaning of support for these carers is twofold: it is a self-evident struggle for the good life of their relatives and that they want to be carers in partnership. The healthcare system must recognize the efforts of carers and include them in the strategic planning and operational stages of care and treatment for people with long-term illness.

Development and Psychometric Testing of the Caregiver Self-Efficacy in Contributing to Patient Self-Care Scale

OBJECTIVES

Caregiver self-efficacy-a caregiver's belief in his/her ability to contribute to patient self-care-is associated with better patient and caregiver outcomes in single chronic conditions. It is, however, unknown if caregiver self-efficacy improves patient and caregiver outcomes in multiple chronic conditions (MCCs) because there is no instrument to measure this variable. We developed the 10-item Caregiver Self-Efficacy in Contributing to patient Self-Care (CSE-CSC) scale for that purpose, and we tested its psychometric characteristics in caregivers of patients with MCCs.

METHODS

In this cross-sectional multisite study, we tested the structural validity of the CSE-CSC scale with exploratory and confirmatory factor analysis, and we tested construct validity by correlating CSE-CSC scores with those of the Caregiver Contributions to Self-Care of Chronic Illness Inventory. We also tested reliability, and precision of the CSE-CSC scale.

RESULTS

The 358 enrolled caregivers (mean age 54.6 years; 71.5% female) cared for patients with an average of 3.2 chronic conditions. Structural validity was good, and it showed 2 factors within the scale. Construct validity showed significant correlations between scores of the CSE-CSC scale and the Caregiver Contributions to Self-Care of Chronic Illness Inventory. Reliability coefficients were between 0.90 and 0.97. Measurement error yielded satisfactory results.

CONCLUSIONS

The CSE-CSC scale is valid, reliable, and precise in measuring caregiver self-efficacy in contributing to patient self-care in MCCs. Because caregiver self-efficacy is a modifiable variable, the CSE-CSC scale can be used in clinical practice and research to improve patient and caregiver outcomes.

Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non-adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes.

OBJECTIVES

To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web-based clinical trial registers.

SELECTION CRITERIA

RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow-up by a health professional (e.g. telephone, text message or face-to-face), multi-component interventions, and interventions to improve inhaler technique.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ).

MAIN RESULTS

We included 14 trials (2191 participants) in the analysis with follow-up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI -3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi-component interventions Eight studies (30 to 734 participants) reported multi-component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi-component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I² = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi-component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD-related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very certainty).

AUTHORS' CONCLUSIONS

Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all-cause or COPD-related), or deaths (very low certainty). Multi-component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist-led approaches) (low certainty), and fewer people may have COPD-related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes.

Smart About Meds (SAM): a pilot randomized controlled trial of a mobile application to improve medication adherence following hospital discharge

Objective

The objectives of this pilot study were (1) to assess the feasibility of a larger evaluation of Smart About Meds (SAM), a patient-centered medication management mobile application, and (2) to evaluate SAM’s potential to improve outcomes of interest, including adherence to medication changes made at hospital discharge and the occurrence of adverse events.

Materials and Methods

We conducted a pilot randomized controlled trial among patients discharged from internal medicine units of an academic health center between June 2019 and March 2020. Block randomization was used to randomize patients to intervention (received access to SAM at discharge) or control (received usual care). Patients were followed for 30 days post-discharge, during which app use was recorded. Pharmacy claims data were used to measure adherence to medication changes made at discharge, and physician billing data were used to identify emergency department visits and hospital readmissions during follow-up.

Results

Forty-nine patients were eligible for inclusion in the study at hospital discharge (23 intervention, 26 control). In the 30 days of post-discharge, 15 (65.2%) intervention patients used the SAM app. During this period, intervention patients adhered to a larger proportion of medication changes (83.7%) than control patients (77.8%), including newly prescribed medications (72.7% vs 61.7%) and dose changes (90.9% vs 81.8%). A smaller proportion of intervention patients (8.7%) were readmitted to hospital during follow-up than control patients (15.4%).

Conclusion

The high uptake of SAM among intervention patients supports the feasibility of a larger trial. Results also suggest that SAM has the potential to enhance adherence to medication changes and reduce the risk of downstream adverse events. This hypothesis needs to be tested in a larger trial.

Trial registration

Clinicaltrials.gov, registration number NCT04676165.

Caregivers' experiences of contributing to patients' self-care in Chronic Obstructive Pulmonary Disease: A thematic synthesis of qualitative studies

Aim

To identify, analyze and synthesize qualitative studies on caregivers’ experiences of contributions to the self‐care of patients with Chronic Obstructive Pulmonary Disease (COPD).

Background

COPD patients perform daily self‐care behaviours to manage the disease. With aging and disease progression, patients need to rely on the contributions of informal caregivers, usually family members, for disease management. Caregivers’ normal or habitual contributions to patients’ self‐care have not yet been completely investigated.

Design

Thematic synthesis of qualitative studies.

Data sources

CINAHL, EMBASE, PubMed, PsycINFO, Web of Science, Scopus, Emcare and OpenGrey databases were searched from inception to September 2020. The search was restricted to English‐language papers.

Review methods

Studies were critically appraised using the Critical Appraisal Skills Programme checklist. The initial line‐by‐line codes were aggregated into descriptive themes from which analytical themes were derived.

Results

Fifteen papers from nine countries, published 2009–2020, were included. Six analytical themes encompassing 22 descriptive themes were identified and grouped in two overarching themes describing caregivers’ experiences of contributions to patients’ self‐care during the stable and exacerbation phases of COPD. In the stable phases, caregivers contribute through maintaining disease stability, promoting healthy behaviours, fostering normal life and helping perform daily activities. During exacerbations, caregivers contribute through assessing, monitoring and managing symptoms in collaboration with patients or autonomously. They contribute by performing actions, motivating patients, organizing care, sensing variations in symptoms, acquiring knowledge and educating patients, making decisions, communicating and collaborating with healthcare providers and patients and advocating for patients.

Conclusion

This thematic synthesis enlarges knowledge of caregivers’ contributions to patients’ self‐care in COPD, detailing the ways by which caregivers provide care to patients.

Impact

Contributing daily to the self‐care of a family member with COPD is a complex experience. Nurses need to acknowledge the importance of caregivers’ contributions to patient disease management and develop effective educational interventions to support them.

Caregiver Experiences and Roles in Care Seeking During COPD Exacerbations: A Qualitative Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating illness characterized by exacerbations that require timely intervention. COPD patients often rely on informal caregivers-relatives or friends-for assistance with functioning and support. Caregivers perform roles that may be particularly important during acute exacerbations in monitoring symptoms and seeking medical intervention. However, little is known about caregivers' roles and experiences as they support their patients during exacerbations.

PURPOSE

To explore the experiences, roles in care seeking, and needs of caregivers during COPD exacerbations.

METHODS

Semi-structured interviews were conducted with 24 caregivers of Veterans with COPD who experienced a recent exacerbation. Interviews were recorded, transcribed, and analyzed using inductive content analysis.

RESULTS

Five themes arose: (a) caregivers reported continuously monitoring changes in patients symptom severity to identify exacerbations; (b) caregivers described emotional reactions evoked by exacerbations and constant vigilance; (c) caregivers described disagreements with their patient in interpreting symptoms and determining the need for care seeking; (d) caregivers noted uncertainty regarding their roles and responsibilities in pursuing care and their approaches to promote care varied; and (e) expressed their need for additional information and support. Caregivers of patients with COPD often influence whether and when patients seek care during exacerbations. Discrepancies in symptom evaluations between patients and caregivers paired with the lack of information and support available to caregivers are related to delays in care seeking. Clinical practice should foster self-management support to patient-caregiver dyads to increase caregiver confidence and patient openness to their input during exacerbations.

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.

Caregiver contribution to self-care and its associated variables among caregivers of ostomy patients: Results of a cross-sectional study

AIMS AND OBJECTIVES

To describe caregiver contribution (CC) to ostomy self-care and identify its associated variables among caregivers of ostomy patients.

BACKGROUND

Self-care is essential for ostomy patients, but it can be difficult to perform. In these cases, caregivers play a key role in promoting self-care behaviours. So far, the CC to ostomy self-care has not been investigated thoroughly.

DESIGN

This is a cross-sectional and multicentre study conducted at seven outpatient clinics of two Italian regions.

METHODS

We recruited 252 caregivers between February 2017-May 2018. The Caregiver Contribution to Ostomy Self-Care Index (CC-OSCI) was used to measure CC to ostomy self-care. Three multivariable linear regression models were fitted to identify variables associated with CC dimensions (maintenance, monitoring and management). The STROBE checklist was used to report the present study.

RESULTS

The sample (mean age = 58.73, SD = 13.98) was mostly female (80.60%), unemployed (58.70%) and resided with the patient (81.00%). Caregivers being employed and those declaring more hours of contribution per week were associated with a significantly lower contribution to self-care maintenance. Caregivers with lower levels of education and those residing with the patient were less likely to contribute to CC to self-care monitoring. Spousal caregivers and those with higher preparedness contributed significantly lower to CC to self-care management.

CONCLUSIONS

We found a variety of sociodemographic factors associated with CC to ostomy self-care.

RELEVANCE TO CLINICAL PRACTICE

Sociodemographic variables associated with CC to ostomy self-care can help clinicians develop more tailored educational interventions for caregivers who find their contribution challenging.

Personalized Medication Adherence Management in Asthma and Chronic Obstructive Pulmonary Disease: A Review of Effective Interventions and Development of a Practical Adherence Toolkit

BACKGROUND

The management of medication nonadherence of patients with asthma or chronic obstructive pulmonary disease (COPD) remains challenging. Given the multitude of underlying causes, a personalized approach is required. The Test of Adherence to Inhalers (TAI) can identify reasons for nonadherence, but it does not provide guidance regarding how to act effectively after results.

OBJECTIVE

To develop a practical, evidence-based decision support toolkit for health care professionals managing adult patients with asthma and/or COPD, by matching TAI-identified adherence barriers to proven effective adherence-enhancing interventions.

METHODS

We performed a literature review in PubMed and Embase identifying interventions that enhanced medication adherence in adult patients with asthma and/or COPD. Randomized controlled trials published in English with full texts available were included. Effective interventions assessed by the Cochrane risk of bias tool were categorized, matched with specific TAI responses, and developed into a practical TAI Toolkit. The Toolkit was assessed for content and usability (System Usability Scale) by a multidisciplinary group of health care professionals.

RESULTS

In total, 40 randomized controlled trials were included in the review. Seven effective interventions categories were identified, informing the TAI Toolkit: reminders, educational interventions, motivational strategies, feedback on medication use, shared decision-making, simplifying the medication regimen, and multiple component interventions. Health care professionals rated the TAI Toolkit with a mean System Usability Scale score of 71.4 (range, 57.5-80.0).

CONCLUSIONS

Adherence can be improved using the different interventions that the TAI Toolkit helps select. The TAI Toolkit was well-received by health care professionals. Further research is required to test its validity, practicality, and effectiveness in practice.

What could prevent chronic condition admissions assessed as preventable in rural and metropolitan contexts? An analysis of clinicians' perspectives from the DaPPHne study

INTRODUCTION

Reducing potentially preventable hospitalisations (PPH) is a priority for health services. This paper describes the factors that clinicians perceived contributed to preventable admissions for angina, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), and what they considered might have been done in the three months leading up to an admission to prevent it.

METHODS

The study was conducted in a rural and a metropolitan health district in NSW, Australia. Expert Panels reviewed detailed case reports to assess preventability. For those admissions identified as preventable, comments from clinicians indicating what they perceived could have made a difference and/or been done differently to prevent each of the preventable admissions were analysed qualitatively.

RESULTS

148 (46%) of 323 admissions were assessed as preventable. Across the two districts, the most commonly identified groups of contributing factors to preventable admissions were: 'Systems issues: Community based services missing or inadequate or not referred to'; 'Patient issues: Problems with adherence/self-management'; and 'Clinician issues: GP care inadequate'. In some instances, important differences drove these groups of factors. For example, in the rural district 'Systems issues: Community based services missing or inadequate or not referred to' was largely driven by social and welfare support services missing/inadequate/not referred to, whereas in the metropolitan district it was largely driven by community nursing, allied health, care coordination or integrated care services missing/inadequate/not referred to. Analyses revealed the complexity of system, clinician and patient factors contributing to each admission. Admissions for COPD (rural) and CHF (metropolitan) admissions showed greatest complexity.

DISCUSSION AND CONCLUSION

These findings suggest preventability of individual admissions is complex and context specific. There is no single, simple solution likely to reduce PPH. Rather, an approach addressing multiple factors is required. This need for comprehensiveness may explain why many programs seeking to reduce PPH have been unsuccessful.

Family members' experiences and expectations of self-management counseling while caring for a person with chronic obstructive pulmonary disease: a systematic review of qualitative evidence

OBJECTIVE

The objective of this review was to identify and synthesize existing evidence on the experiences and expectations of self-management counseling of adult family members who are informal caregivers of a person with chronic obstructive pulmonary disease (COPD) in the context of inpatient or outpatient care.

INTRODUCTION

Chronic obstructive pulmonary disease is the fourth leading cause of mortality and morbidity worldwide. It is a progressive, lifelong and unpredictable disease. As the disease progresses, both the people with COPD and their family members require information and practical skills to manage the disease. The role of family members is particularly important at the advanced stage of COPD. This systematic review examined family members' experiences and expectations of self-management counseling.

INCLUSION CRITERIA

This review considered qualitative studies that investigated adult (older than18 years) family members' experiences or expectations of COPD self-management counseling in the context of inpatient or outpatient care. "Family member" refers to a person who is an informal caregiver because of his or her relationship to the person with COPD.

METHODS

A three-step search strategy was utilized in this review. The search strategy aimed to find published and unpublished studies in English and Finnish. The databases MEDLINE, CINAHL, PsycINFO, Scopus and the Finnish medical bibliographic database, Medic, were searched. The search was conducted in December 2015 and updated in September 2018. Titles and abstracts were screened by two independent reviewers for the review's inclusion criteria. Eligible studies were then critically appraised by two independent reviewers for methodological quality. The findings and illustrations of the findings were extracted and assigned a level of credibility. The qualitative research findings were pooled using the JBI method of meta-aggregation.

RESULTS

Ten papers were selected for inclusion in this review. These studies were published from 2002 to 2017. The quality of all included studies was at least moderate. Each study had a total score between 7 and 10 on the JBI Critical Appraisal Checklist for Qualitative Research. The following four synthesized findings were aggregated from nine categories and 39 study findings: i) Family members' experiences with unresponsive behavior from health professionals, ii) Family members' experiences of unmet needs in self-management counseling, iii) Family members' information needs concerning COPD management, and iv) Family members' information needs concerning coping strategies.

CONCLUSIONS

The synthesized findings indicate that family members are frustrated by the shortcomings of self-management counseling. They also feel unprepared for and uncertain about their caring role. They need more information about COPD and coping strategies for COPD. Counseling is essential to high-quality care and should be offered to family members caring for a loved one at any stage of COPD.

The health-related quality-of-life of chronic obstructive pulmonary disease patients and disease-related indirect burdens

BACKGROUND/AIMS

Many chronic obstructive pulmonary disease (COPD) patients have physical limitations. We investigated EuroQol five-dimensions five-level (EQ-5D-5L) of COPD patients to assess quality of life, and assessed indirect burden including time expenditure to visit doctor, home care rate, and caregiver related burden.

METHODS

We recruited 355 COPD patients according to severity of airflow limitation that severity was set at 10% mild, 40% moderate, 30% severe, and 20% very severe in two primary and 11 secondary/tertiary hospitals. Eligible patients were aged ≥ 40 years, who have been diagnosed with COPD for more than 1 year. Patients were recruited between June 2015 and October 2016.

RESULTS

The quality of life tended to decline with age, from mild to very severe impairment, as revealed by the EQ-5D-5L scores and the EQ visual analog scale. Family caregivers accompanied 22.6% of patients who visited outpatient clinics, and 25% of stage IV COPD patients. During emergency visits and hospitalization, this figure increased to > 60%. The home care rates were 28.5% for stage I patients, and 34.4, 31.8, and 52% for stage II to IV patients, respectively. The percentage of caregivers who stopped working was 13.6%. The EQ-5D index was strongly associated with the dyspnea scale (r = -0.64, p < 0.001). The average required time to see a doctor and visit the pharmacy was 154 minutes.

CONCLUSION

In patients with COPD, the EQ-5D index decreased and disease-related home caregiving increased with airflow limitation. We considered the caregiver- related burden when making a strategy for COPD management.

Informal carers and peer support in pulmonary rehabilitation: an underutilized resource?

PURPOSE OF REVIEW

The aim of this review is to discuss the recent literature relating to the involvement of informal carers and peer support in pulmonary rehabilitation.

RECENT FINDINGS

Informal carers and peer support have been identified by both patients and healthcare workers as a crucial component in the care of those with chronic respiratory disease at home. Pulmonary rehabilitation, a cornerstone in the management of patients with breathlessness, is limited in its clinical effectiveness by poor referral, uptake and completion rates. Engagement of informal carers and support from peers may help maximize the utilization of pulmonary rehabilitation.

SUMMARY

This review highlights the need for more good-quality randomized controlled trials in identifying suitable interventions that may increase uptake and completion of pulmonary rehabilitation programmes. Qualitative studies have highlighted the potential for informal carers and peer support to play a key role in the design of research programmes, and in the delivery of pulmonary rehabilitation. This needs to be addressed in future research.

A cohort study of medication adherence among patients with chronic obstructive pulmonary disease in Egypt

Chronic obstructive pulmonary disease (COPD), the most common chronic respiratory disease, is expected to become the third leading cause of death worldwide in 2020. A prospective cohort study conducted in 2017 and 2018 aimed to identify factors associated with inhaler treatment adherence in patients with COPD in Cairo (Egypt). Physicians collected data regarding patient deaths, treatment-related adverse events, and patients’ social support (no support, patient, support by spouse, children, and siblings) from their patients with COPD. The reason for treatment discontinuation was categorized as per patient decision or per physician decision. Adherence was categorized as treatment continued or treatment stopped. Patients who decided to stop treatment were considered non-adherent to COPD therapy. A total of 1311 patients as well as 98 physicians and 205 pharmacists were included. Pharmacists and social support (spouse, children/siblings) were identified as key positive factors in patients’ decisions to adhere to their prescribed COPD treatment regimens. A total of 631 patients (48.1%) stopped the treatment, including 170 (27.0%) due to patient decision and 55 (8.7%) deceased. After Cox model analysis, a low number of patients (6–19) attended by the pharmacist was a significant predictive factor (hazard ratio [HR] = 1.40, 95% confidence interval [CI] = 1.03–1.91, p = 0.03) for deciding to stop treatment. A wife or husband (HR = 0.85, 95% CI = 0.72–1.02, p = 0.07) as well as children or brother/sister (HR = 0.77, 95% CI = 0.57–1.04, p = 0.08) provided a positive effect for continued treatment. Pharmacists are well positioned to play a role as an essential public health resource that can help improve adherence as well as social support that should be considered as an important component to improve adherence to long-term therapy in COPD as well as other chronic non-communicable diseases in low- and middle-income countries.

Associations Among Perceived Control, Depressive Symptoms, and Well-being in Patients With Heart Failure and Their Spouses: A Dyadic Approach

BACKGROUND

High levels of perceived control and lower levels of depressive symptoms are associated with better well-being in both patients with heart failure and their spouses at an individual level. However, there is a knowledge gap about how these individual factors have reciprocal influences on partners' well-being within the patient-spouse dyads.

OBJECTIVE

The aims of this study were to examine dyads of patients with heart failure and their spouses on whether the patients' perceived control over the management of heart failure and depressive symptoms predicts their own and their spouses' physical and emotional well-being and to examine whether patients' perceived control predicts their own and their spouses' depressive symptoms.

METHODS

A total 155 patient-spouse dyads (patients: 75% male, mean age of 71 years, 53% classified as New York Heart Association III; spouses: 75% female, mean age of 69 years) were recruited from 2 hospital-based outpatient heart failure clinics. Participants completed the Control Attitude Scale, the Beck Depression Inventory, and the Short-Form 36. Dyadic data were analyzed using multilevel regression of the actor-partner interdependence model.

RESULTS

Perceived control had an actor effect on emotional well-being only for patients, and there were partner effects of perceived control on emotional well-being for both patients and their spouses. Depressive symptoms exhibited an actor effect on physical and emotional well-being for patients and spouses, but there were no partner effects of depressive symptoms on emotional well-being. Perceived control had partner effects on depressive symptoms for patients and spouses, but an actor effect of depressive symptoms was only found for patients.

CONCLUSION

In an interdependent relationship within the patient-spouse dyads, each dyad member's perceived control influenced their partner's emotional well-being as well as depressive symptoms. The findings suggest development of dyadic interventions that can increase perceived control over the heart condition.

Methodology and baseline characteristics of a randomized controlled trial testing a health care professional and peer-support program for patients with chronic obstructive pulmonary disease: The BREATHE2 study

BACKGROUND

Self-management support (SMS) for patients with COPD can improve health-related quality of life (HRQOL). However, it remains unclear what SMS strategies are most effective. Using peer support to advance self-management is promising, as peer supporters possess credibility and can serve as role models.

METHODS

We conducted a single-blinded RCT comparing the effectiveness of two strategies to support patients with COPD. The strategies were 'Health Care Professional (HCP)' and 'HCP Plus Peer' support. Peer support was provided by patients with COPD who have stopped smoking, completed an acute pulmonary rehabilitation program, and met the requirements for becoming a peer supporter. We enrolled patients receiving treatment at inpatient and outpatient settings. Patients were encouraged to invite one family-caregiver to enroll with them. The primary outcome measure was the change in HRQOL at 6 months post enrollment. Secondary outcomes included COPD-related and all-cause hospitalizations and ED visits. Caregiver outcomes included preparedness for caregiving, caregiver stress, and coping.

RESULTS

A total of 292 patients as well as 50 family-caregivers were enrolled. The average patient age was 67.3 yrs. (SD 9.4), 61% were female and 26% were African-Americans. The majority of caregivers were females (68%) and were a spouse/partner (58%).

DISCUSSION

This study tested a dual strategy for providing support to patients with COPD that incorporates peer and health care professional support. The study had minimal exclusion criteria. If shown effective, the study offers a program of peer support that can be readily implemented in health care settings.

Patient and caregiver contributions to self-care in multiple chronic conditions: A multilevel modelling analysis

BACKGROUND

Multiple chronic conditions (MCC) are highly prevalent worldwide, especially among older populations. Patient self-care and care partner (or caregiver) contributions to self-care are recommended to reduce the impact of MCC and improve patients' outcomes.

OBJECTIVES

To describe patient self-care and care partner contributions to self-care and to identify determinants of patient self-care and care partner contributions to self-care at the patient and care partner level.

DESIGN

Multicentre cross-sectional study.

SETTING

Outpatient and community settings in Italy.

PARTICIPANTS

A sample of 340 patients with MCC and care partner dyads was recruited between 2017 and 2018.

METHODS

We measured patient's self-care and care partner contributions to self-care in dyads using the Self-care of Chronic Illness Inventory and the Caregiver Contribution to Self-care of Chronic Illness Inventory. To control for dyadic interdependence, we performed a multilevel modelling analysis.

RESULTS

Patients' and care partners' mean ages were 76.65 (± 7.27) and 54.32 (± 15.25), respectively. Most care partners were female and adult children or grandchildren. The most prevalent chronic conditions in patients were diabetes (74%) and heart failure (34%). Patients and care partners reported higher levels of self-care monitoring than self-care maintenance and management behaviours. Important patient clinical determinants of self-care included cognitive status, number of medications and type of chronic condition. Care partner determinants of self-care contributions included age, gender, education, perceived income, care partner burden, caregiving hours per week and the presence of a secondary care partner.

CONCLUSIONS

Our findings support the importance of taking a dyadic approach when focusing on patients with MCC and their care partners. More dyadic longitudinal research is recommended to reveal the modifiable determinants of self-care and the complex relationships between patients and care partners in the context of MCC.

Social Risk Factors for Medication Nonadherence: Findings from the CARDIA Study

Objectives: Nonadherence to medications has been documented, but the combined effect of social risk factors on medication nonadherence has not been investigated. Methods: We conducted a cross-sectional analysis of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort. The sample (N = 1506) included subjects who at Year 20 (2005-06) were taking prescription medications and completed a 4-item Medication Adherence Scale. Social risk factors were education of high school or less, annual household income <$25,000, high financial strain, high chronic stress, low social support, and high social strain. Results: In a fully adjusted logistic regression model, income <$25,000 (OR = 2.37 [95% CI 1.12-4.98], p < .05) and high chronic stress (OR = 2.07 [95% CI 1.09-3.94], p < .05) were significantly associated with medication nonadherence. Individuals with ≥3 social risk factors had >3 times higher odds of nonadherence than counterparts with no social risk factors (OR = 3.26 [95% CI 1.72-6.19], p < .001). Conclusion: Low income and chronic stress are associated with medication nonadherence, and the odds of nonadherence increase with the accumulation of social risk factors. Findings may be used to develop risk prediction tools to identify individuals who can benefit from adherence-promoting interventions.

Benefits of the 'village': a qualitative exploration of the patient experience of COPD in rural Australia

OBJECTIVES

This study sought to explore patients' experiences of living with, and adapting to, chronic obstructive pulmonary disease (COPD) in the rural context. Specifically, our research question was 'What are the barriers and facilitators to living with and adapting to COPD in rural Australia?'

DESIGN

Qualitative, semi-structured interviews. Conversations were recorded, transcribed verbatim and analysed using thematic analysis following the COnsolidated criteria for REporting Qualitative research guidelines.

SETTING

Patients with COPD, admitted to a subregional hospital in Australia were invited to participate in interviews between October and November 2016.

MAIN OUTCOME MEASURES

Themes were identified that assisted with understanding of the barriers and facilitators to living with, and adapting to, COPD in the rural context.

RESULTS

Four groups of themes emerged: internal facilitators (coping strategies; knowledge of when to seek help) and external facilitators (centrality of a known doctor; health team 'going above and beyond' and social supports) and internal/external barriers to COPD self-management (loss of identity, lack of access and clear communication, sociocultural challenges), which were moderated by feelings of inclusion or isolation in the rural community or 'village'.

CONCLUSIONS

Our findings suggest that community inclusion enhances patients' ability to cope and ultimately self-manage COPD. This is facilitated by living in a supportive 'village' environment, and included a central, known doctor and a healthcare team willing to go 'above and beyond'. Understanding, or supplementing, these social networks within the broader social structure may assist people to manage chronic disease, regardless of rural or metropolitan location.

Living environment, social support, and informal caregiving are associated with healthcare seeking behaviour and adherence to medication treatment: A cross-sectional population study

Despite the well-known associations between local environment and health, few studies have focused on environment and healthcare utilisation, for instance healthcare seeking behaviour or adherence. This study was aimed at analysing housing type, behaviour based on perceived local outdoor safety, social support, informal caregiving, demographics, socioeconomics, and long-term illness, and associations with health-seeking and adherence behaviours at a population level. This study used data from the Swedish National Public Health Survey 2004-2014, an annually repeated, large sample, cross-sectional, population-based survey study. In all, questionnaires from 100,433 individuals were returned by post, making the response rate 52.9% (100,433/190,000). Descriptive statistics and multiple logistic regressions were used to investigate associations between explanatory variables and the outcomes of refraining from seeking care and non-adherence behaviour. Living in rented apartment, lodger, a dorm or other was associated with reporting refraining from seeking care (adjusted OR 1.16, 95% CI 1.00-1.22), and non-adherence (adjusted OR 1.22; 95% CI 1.13-1.31). Refraining from going out due to a perceived unsafe neighbourhood was associated with refraining from seeking care (adjusted OR 1.59, 95% CI 1.51-1.67) and non-adherence (adjusted OR 1.26, 95% CI 1.17-1.36). Social support and status as an informal caregiver was associated with higher odds of refraining from seeking medical care and non-adherence. This study suggests that living in rental housing, refraining from going out due to neighbourhood safety concerns, lack of social support or informal caregiver status are associated with lower health-seeking behaviour and non-adherence to prescribed medication.

Status of and strategies for improving adherence to COPD treatment

Despite the wide application of adherence as a concept, the definition, evaluation and improvement of the adherence to treatment by patients with chronic obstructive pulmonary disease (COPD) still present some challenges. First, it is necessary to clearly define the concepts of treatment adherence, compliance and persistence. Second, it is critical to consider the various methods of evaluating and quantifying adherence when interpreting adherence studies. In addition, the advantages and disadvantages of the different ways of measuring treatment adherence should be taken into account. Another subject of some debate is the number of variables associated with COPD treatment adherence. Adherence is a complex concept that goes beyond the dosage or the use of inhalation devices, and a number of variables are involved in determining adherence, from the clinical aspects of the disease to the patient's confidence in the doctor's expertise and the level of social support experienced by the patient. Notably, despite these challenges, the importance of adherence has been well established by clinical trials and routine clinical practice. The available evidence consistently shows the substantial impact that a lack of adherence has on the control of the disease and its long-term prognosis. For these reasons, the correct evaluation of therapeutic adherence should be a key objective in clinical interviews of patients. In recent years, various initiatives for improving adherence have been explored. All these initiatives have been based on patient education. Therefore, health care professionals should be aware of the issues pertaining to adherence and take the opportunity to educate patients each time they contact the health care system.

Triangulated perspectives on outcomes of pulmonary rehabilitation in patients with COPD: a qualitative study to inform a core outcome set

Introduction:

Pulmonary rehabilitation implies a comprehensive assessment. Although several outcomes are commonly measured, those are selected mainly by health professionals and researchers, with the voice of patients and informal caregivers being minimally captured. Qualitative studies are fundamental to enhance our knowledge on perspectives of different stakeholders involved in pulmonary rehabilitation.

Objective:

This study aimed to explore the views of different stakeholders on outcomes of pulmonary rehabilitation, contributing to one of the stages of a core outcome set for pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD).

Methods:

Semi-structured interviews were conducted with 12 patients with COPD, 11 informal carers and 10 health professionals. Data were analysed with content analysis, followed by thematic analysis to gain deeper understanding of the different perspectives.

Results:

A total of 44 outcomes were identified, being the most reported ‘improving functional performance’ (67%) and ‘reducing and taking control over dyspnoea’ (64%). Five relevant themes across stakeholders were generated: having a healthy mind in a healthy body; I can(’t) do it; feeling fulfilled; knowing more, doing better and avoiding doctors and expenses. Although perspectives were mostly consensual, some outcomes were only valued by health professionals (e.g. pulmonary function) or by patients and informal carers (e.g. quality of sleep).

Conclusion:

Views of the different stakeholders on outcomes of pulmonary rehabilitation were similar although, some specificities existed. Comprehensive assessments are needed to reflect what is valued by the different stakeholders in pulmonary rehabilitation. This study contributed to a future core outcome set in this field.

Adherence to inhaled therapy and its impact on chronic obstructive pulmonary disease (COPD)

Background

COPD is a treatable disease with increasing prevalence worldwide. Treatment aims to stop disease progression, to improve quality of life, and to reduce exacerbations. We aimed to evaluate the association of the stage of COPD on adherence to inhaled therapy and the relationship between adherence and COPD exacerbations.

Methods

A retrospective analysis of patients hospitalized for acute exacerbation of COPD in a tertiary care hospital in Upper Austria and discharged with a guideline conform inhaled therapy was performed. Follow-up data on medical utilization was recorded for the subsequent 24 months. Adherence to inhaled therapy was defined according to the percentage of prescribed inhalers dispensed to the patient and classified as complete (> 80%), partial (50–80%) or low (< 50%).

Results

Out of 357 patients, 65.8% were male with a mean age of 66.5 years and a mean FEV₁ of 55.0%pred. Overall, 35.3% were current smokers, and only 3.9% were never-smokers. In 77.0% inhaled triple therapy (LAMA + LABA + ICS) was prescribed. 33.6% showed complete adherence to their therapy (33.2% in men, 34.4% in women), with a mean age of 67.0 years. Mean medication possession ratio by GOLD spirometry class I – IV were 0.486, 0.534, 0.609 and 0.755, respectively (p = 0.002). Hence, subjects with complete adherence to therapy had a significantly lower FEV₁ compared to those with low adherence (49.2%pred. vs 59.2%pred., respectively; p <  0.001).

The risk of exacerbations leading to hospitalization was 10-fold higher in GOLD spirometry class IV compared to GOLD spirometry class I, which was even more evident in multivariate analysis (OR 13.62).

Conclusion

Complete adherence to inhaled therapy was only seen in 33.6% and was higher among those with more severe COPD.

Trial registration

Not applicable.

Association between Social Support and Self-Care Behaviors in Adults with Chronic Obstructive Pulmonary Disease

RATIONALE

Higher social support is associated with a better quality of life and functioning in adults with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To determine the association between structural and functional social support and self-care behaviors in adults with COPD.

METHODS

This was a longitudinal study using data from the CASCADE (COPD Activity: Serotonin Transporter, Cytokines, and Depression) study, which was focused on depression and functioning in COPD. Physical activity was measured with a validated accelerometer at baseline, year 1, and year 2. Additional self-care behaviors included pulmonary rehabilitation attendance, smoking status, receipt of influenza and/or pneumococcal vaccinations, and medication adherence. Structural social support indicators included living status, being partnered, number of close friends/relatives, and presence of a family caregiver. Functional social support was measured with the Medical Outcomes Social Support Survey (MOSSS). Mixed-effects and logistic regression models were used.

RESULTS

A total of 282 participants with Global Initiative for Chronic Obstructive Lung Disease stage II to IV COPD were included (age, 68 ± 9 yr; 80% men; FEV₁% predicted, 45 ± 16). For physical activity, participants who lived with others accrued 903 more steps per day than those who lived alone (95% confidence interval [CI], 373-1,433; P = 0.001); increases in the MOSSS total score were associated with more steps per day (β = 10; 95% CI, 2-18; P = 0.02). The odds of pulmonary rehabilitation participation were more than 11 times higher if an individual had a spouse or partner caregiver compared with not having a caregiver (odds ratio [OR], 11.03; 95% CI, 1.93-62.97; P < 0.01). Higher functional social support (MOSSS total score) was associated with marginally lower odds of smoking (OR, 0.99; 95% CI, 0.98-1.00; P = 0.03) and higher odds of pneumococcal vaccination (OR, 1.02; 95% CI, 1.00-1.03; P = 0.02). Social support was not associated with influenza vaccination or medication adherence.

CONCLUSIONS

Structural social support, which was measured by reports of living with others and having a caregiver, was respectively associated with higher levels of physical activity and greater participation in pulmonary rehabilitation in adults with COPD. Our findings reinforce the critical importance of the social environment in shaping patients' success with self-care. Clinical Trial registered with clinicaltrials.gov (NCT01074515).

A Couple-Based Communication Intervention for Hematopoietic Cell Transplantation Survivors and Their Caregiving Partners: Feasibility, Acceptability, and Change in Process Measures

Hematopoietic cell transplantation (HCT) poses significant challenges for recipients and their caregiving partners. Couples may refrain from talking about treatment-related fears and concerns to minimize distress. This single-group, pre-post study examined feasibility and acceptability of an intervention designed to optimize communication between HCT patients and partners; it also assessed change in process measures. Couples met with a therapist 5 times to learn skills for disclosing illness-related thoughts and feelings and responding supportively to one another. The extent to which participants disclosed thoughts, feelings, and information during the session and felt supported was assessed at the close of each session. Forty of 89 eligible couples consented (45%). Thirty couples commenced intervention 1-month post-transplant; 26 of these completed all sessions (87%) and 27 completed follow-up (90%). Ratings of self-disclosure and feeling supported by one's partner increased linearly across intervention sessions among both patients and caregivers (all P ≥ .01). Ratings of satisfaction with the intervention were high. HCT couples can be recruited and retained for this intervention. They found it acceptable and were amenable to skills training. A randomized trial is needed to test efficacy and to identify moderators of treatment response.

Living Arrangements Modify the Relationship Between Depressive Symptoms and Self-care in Patients With Heart Failure

BACKGROUND

Depressive symptoms hinder heart failure patients' engagement in self-care. As social support helps improve self-care and decrease depressive symptoms, it is possible that social support buffers the negative impact of depressive symptoms on self-care.

OBJECTIVE

The purpose of this study is to examine the effect of living arrangements as an indicator of social support on the relationship between depressive symptoms and self-care in heart failure patients.

METHODS

Stable heart failure patients (N = 206) completed the Patient Health Questionnaire-9 to measure depressive symptoms. Self-care (maintenance, management, and confidence) was measured with the Self-Care of Heart Failure Index. Path analyses were used to examine associations among depressive symptoms and the self-care constructs by living arrangements.

RESULTS

Depressive symptoms had a direct effect on self-care maintenance and management (standardized β = -0.362 and -0.351, respectively), but not on self-care confidence in patients living alone. Depressive symptoms had no direct or indirect effect on any of the 3 self-care constructs in patients living with someone.

CONCLUSIONS

Depressive symptoms had negative effects on self-care in patients living alone, but were not related to self-care in patients living with someone. Our results suggest that negative effects of depressive symptoms on self-care are buffered by social support.

The Impact of Partnership Status on Diabetes Control and Self-Management Behaviors

According to the Centers for Disease Control and Prevention, diabetes affects 29.1 million people in the United States. Marriage has been suggested to have a protective effect on overall health outcomes, but few studies have evaluated the role of partnership status on patients with type 2 diabetes. This study aimed to assess this role of partnership status on diabetes control and self-management behaviors. Patients with type 2 diabetes taking at least one oral hypoglycemic agent were assessed over a 3-month period to measure hemoglobin A1c (HbA1c) changes and adherence to medication, exercise, diet, and glucose monitoring. Partnered participants were more likely to adhere to their medications, but there was no significant difference in HbA1c changes over 3 months or exercise, diet, or glucose monitoring adherence. This study suggests that being partnered improves medication adherence; further analysis with a larger population is required to fully assess the role of partner support for patients with type 2 diabetes.

Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes

Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.

The correlates of social capital and adherence to healthy lifestyle in patients with coronary heart disease

OBJECTIVE

To investigate the correlates of social capital and adherence to healthy lifestyle in patients with coronary heart disease (CHD).

METHODS

This register-based, cross-sectional study consisted of individuals diagnosed with CHD at four community health service centers, Shanghai, China, between April and July 2016 (n=609). The sociodemographic characteristics, social capital, adherence to physical activity, and nutrition data were obtained through face-to-face interviews. Social capital was assessed by social participation, social networking, social support, social trust, and sense of belonging. Physical activity and nutrition were measured with the Health-Promoting Lifestyle Profile II. The independent two-sample t-test and Pearson's correlations were used to analyze associations among variables. Hierarchical multiple regression models were used to evaluate effects of social capital on adherence to physical activity and nutrition.

RESULTS

The average age of the sample was 60.87 (standard deviation [SD] =6.91), with 54.4% being male and 45.6% female. The average score of physical activity and nutrition were 2.38 (SD =0.59) and 2.78 (SD =0.50), respectively. The final model significantly explained 28.9% of variance in physical activity (F=34.96, P<0.001) and 30.5% of variance in nutrition (F=37.73, P<0.001). Most of the subdimensions of social capital were significantly associated with physical activity and nutrition, after controlling for marital status and education level.

CONCLUSION

The results suggested that social capital was the correlate of adherence to long-term healthy lifestyle, including physical activity and nutrition. These findings highlight the need to take into account social capital in developing intervention strategies to improve the adherence to the long-term healthy lifestyle for patients with CHD.

Adherence to COPD treatment: Myth and reality

COPD is a chronic disease in which effective management requires long-term adherence to pharmacotherapies but the level of adhesion to the prescribed medications is very low and this has a negative influence on outcomes. There are several approaches to detect non-adherence, such as pharmacy refill methods, electronic monitoring, and self-report measures, but they are all burdened with important limitations. Medication adherence in COPD is multifactorial and is affected by patients (health beliefs, cognitive abilities, self-efficacy, comorbidities, psychological profile, conscientiousness), physicians (method of administration, dosing regimen, polypharmacy, side effects), and society (patient-prescriber relationship, social support, access to medication, device training, follow-up). Patient-health care professional communication, especially that between patient and physician or pharmacist, is central to optimizing patient adherence. However, the most realistic approach is to keep in mind that non-adherence is always possible, indeed, probable.

The Social Determinants of Chronic Disease

This review article addresses the concept of the social determinants of health (SDH), selected theories, and its application in studies of chronic disease. Once ignored or regarded only as distant or secondary influences on health and disease, social determinants have been increasingly acknowledged as fundamental causes of health afflictions. For the purposes of this discussion, SDH refers to SDH variables directly relevant to chronic diseases and, in some circumstances, obesity, in the research agenda of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research. The health effects of SDH are initially discussed with respect to smoking and the social gradient in mortality. Next, four leading SDH theories-life course, fundamental cause, social capital, and health lifestyle theory-are reviewed with supporting studies. The article concludes with an examination of neighborhood disadvantage, social networks, and perceived discrimination in SDH research.

Life after Stroke: Coping mechanisms among African Caribbean Women

In the UK, stroke is the third most common cause of death for women and the incidence in African Caribbean women is higher than that in the general population. Stroke burden has major consequences for the physical, mental and social health of African Caribbean women. In order to adjust to life after stroke, individuals affected employ a range of strategies which may include personal, religious (church) or spiritual support (i.e. prayer), individual motivation or resignation to life with a disability. This study explored these areas through the coping mechanisms that African Caribbean women utilised post stroke in the context of stroke recovery and lifestyle modification efforts needed to promote healthy living post stroke. A qualitative approach using interpretative phenomenological analysis was adopted. Seven women were recruited into the study. Semi-structured, in-depth interviews were audio recorded and were transcribed verbatim. Data were analysed using a four-stage framework: familiarisation, sense making, developing themes, and data refinement and analysis. Three main themes on coping emerged: the need to follow medical rules to manage stroke, strength and determination, and the use of religion and faith to cope with life after stroke. These findings illustrate both a tension between religious beliefs and the medical approach to stroke and highlight the potential benefits that religion and the church can play in stroke recovery. Implications for practice include acknowledgement and inclusion of religion- and church-based health promotion in post-stroke recovery.

Undefined and unpredictable responsibility: a focus group study of the experiences of informal caregiver spouses of patients with severe COPD

AIMS AND OBJECTIVES

To explore how spouses of patients with severe chronic obstructive pulmonary disease experience their role as informal caregiver.

BACKGROUND

Informal caregiver spouses are of pivotal importance in the way that patients with chronic obstructive pulmonary disease cope with their daily life, including their opportunity to stay at home and avoid hospitalisations in the last stages of the disease. However, caregiving is associated with increased morbidity and mortality among caregivers. Further understanding of the role as an informal caregiver spouse of patients with severe chronic obstructive pulmonary disease is needed to develop supportive interventions aimed at reducing the caregiver burden.

DESIGN

The study had a qualitative exploratory design. The data collection and analysis were based on framework method. Framework method is a thematic methodology and consists of five key stages: familiarisation, identifying a thematic framework, indexing, charting and mapping & interpretation.

METHODS

Three focus groups were conducted in November 2013 with 22 spouses of patients with severe chronic obstructive pulmonary disease.

RESULTS

Undefined and unpredictable responsibility was found to be the overarching theme describing the informal caregiver role. Underlying themes were: being constantly in a state of alertness, social life modified, maintaining normality, ambivalence in the relationship and a willingness to be involved.

CONCLUSIONS

The informal caregiver spouses experienced ambiguity about expectations from their private and the health professionals' surroundings. The informal caregiver spouses wanted to provide meaningful care for their partners, but sought knowledge and support from the health professionals.

RELEVANCE TO CLINICAL PRACTICE

We recommend that nurses take on the responsibility for including the informal caregiver spouses in those aspects of decision-making that involve the common life of the patients and their spouses.