Treatment demands and differential treatment of patients with cystic fibrosis and their siblings: patient, parent and sibling accounts

Development and preliminary validation of the challenges of living with cystic fibrosis (CLCF) questionnaire: a 46-item measure of treatment burden for parent/carers of children with CF

OBJECTIVE

Treatments for cystic fibrosis (CF) are complex, labour-intensive, and perceived as highly burdensome by caregivers of children with CF. An instrument assessing burden of care is needed.

DESIGN

A stepwise, qualitative design was used to create the CLCF with caregiver focus groups, participant researchers, a multidisciplinary professional panel, and cognitive interviews.

MAIN OUTCOME MEASURES

Preliminary psychometric analyses evaluated the reliability and convergent validity of the CLCF scores. Cronbach's alpha assessed internal consistency and t-tests examined test-retest reliability. Correlations measured convergence between the Treatment Burden scale of the Cystic Fibrosis Questionnaire-Revised (CFQ-R) and the CLCF. Discriminant validity was assessed by comparing CLCF scores in one vs two-parent families, across ages, and in children with vs without Pseudomonas aeruginosa (PA).

RESULTS

Six Challenge subscales emerged from the qualitative data and the professional panel constructed a scoresheet estimating the Time and Effort required for treatments. Internal consistency and test-retest reliability were adequate. Good convergence was found between the Total Challenge score and Treatment Burden on the CFQ-R (r=-0.49, p = 0.02, n = 31). A recent PA infection signalled higher Total Challenge for caregivers (F(23)11.72, p = 0.002).

CONCLUSIONS

The CLCF, developed in partnership with parents/caregivers and CF professionals, is a timely, disease-specific burden measure for clinical research.

Aiming to Improve Equity in Pulmonary Health: Cystic Fibrosis

This review summarizes the evidence of health disparities in cystic fibrosis (CF), an autosomal recessive genetic disorder with substantial variation in disease progression and outcomes. We review disparities by race, ethnicity, socioeconomic status, geographic location, gender identity, or sexual orientation documented in the literature. We outline the mechanisms that generate and perpetuate such disparities across levels and domains of influence and assess the implications of this evidence. We then recommend strategies for improving equity in CF outcomes, drawing on recommendations for the general population and considering approaches specific to people living with CF.

Psychosocial needs and interventions for young children with cystic fibrosis and their families

This review summarises the experiences of young children and their families living with CF during the first five years of life following NBS diagnosis, as well as the options of psychosocial support available to them. We present strategies embedded within routine CF care that focus on prevention, screening, and intervention for psychosocial health and wellbeing that constitute essential components of multidisciplinary care in infancy and early childhood.

The experiences of adolescent siblings of children with rare genetic conditions: "It's made me who I am"

Childhood genetic conditions impact not only the child who is diagnosed but also the day-to-day lives of all members of a family. However, our understanding of the perspectives and needs of unaffected adolescents in families affected by rare genetic conditions is limited. To address this gap, we conducted semi-structured interviews with 10 participants aged 14-20 years, all of whom had a sibling with a rare genetic condition. An interpretive description approach was used to develop a framework that described how participants' experiences of having a sibling with a rare genetic condition shaped the formation of their identity. This experience influenced identity formation both directly, and indirectly through four other phenomena: (1) normalization, of both their own experiences and their siblings' differences; (2) knowledge seeking, regarding their sibling's condition and what uncertainties remained; (3) caretaking, which limited some opportunities and was associated with uncertainty around the future; and (4) social experience, including their relationship with their affected sibling, with their peers, and with the rest of their family participants felt that they were isolated and lacked appropriate supports. The results of this study can help to inform a family-centered approach to genetic counseling and highlight the importance of tailored supports for this population.

Socioeconomic determinants of respiratory health in patients with cystic fibrosis: implications for treatment strategies

INTRODUCTION

Great variation exists in the progression and outcomes of cystic fibrosis (CF) lung disease, due to both genetic and environmental influences. Social determinants mediate environmental exposures and treatment success; people with CF from socioeconomically disadvantaged backgrounds have worse health and die younger than those in more advantaged positions.

AREAS COVERED

This paper reviews the literature on the mechanisms that are responsible for generating and sustaining disparities in CF health, and the ways by which social determinants translate into health advantages or disadvantages in people with CF. The authors make recommendations for addressing social risk factors in CF clinical practice.

EXPERT OPINION

Socioeconomic factors are not dichotomous and their impact is felt at every step of the social ladder. CF care programs need to adopt a systematic protocol to screen for health-related social risk factors, and then connect patients to available resources to meet individual needs. Considerations such as daycare, schooling options, living and working conditions, and opportunities for physical exercise and recreation as well as promotion of self-efficacy are often overlooked. In addition, advocacy for changes in public policies on health insurance, environmental regulations, social welfare, and education would all help address the root causes of CF health inequities.

Coping with cystic fibrosis: An analysis from the sibling's point of view

BACKGROUND

Cystic fibrosis (CF) is a chronic, life-threatening condition that results in life-long morbidity and premature mortality. CF has a significant impact on healthy siblings' adaptation and well-being. Siblings of patients with a chronic disease may experience psychological difficulties, such as anxiety, depression symptoms and troubles in adaptation. This study aimed to explore the participants' experiences of growing up with a CF patient diagnosed at a paediatric age and their adaptation strategies.

METHODS

We enrolled eight CF siblings (adolescents and young adults) in a 6-month focus group sessions programme. Each session had two phases (psychoeducational and experiential). Transcripts were analysed and grouped through grounded theory analysis to elaborate on data-driven theory.

RESULTS

We identified 14 subthemes by which the raw data could be organized. All the subthemes were gathered together according to the axial coding process into six themes (illness, changes, communication, avoidance, normalization, and protection and care). We then grouped the six themes into two main themes ('Growing up with a CF brother or sister' and 'Finding the right distance') and conceptualized the grounded theory 'Keeping the right distance'. The participants described the evolving process of maintaining a balance between the illness of their brother or sister, family organization and their own needs.

CONCLUSIONS

Knowing siblings' experiences and their common strategies to deal with the experience of having a brother or sister with a chronic health condition may be useful to ensure more tailored and specific interventions.

Quantitative and Qualitative Perspectives of Siblings of Children With Cochlear Implants

Purpose The sibling relationship teaches children to navigate social interactions with their peers. However, the presence of an exceptionality, such as hearing loss, in one child can affect the dynamic of this relationship. This article examines quantitative and qualitative effects of having a brother or sister with a cochlear implant (CI) on siblings with typical hearing (TH) to determine how children with TH perceive their sibling with a CI and how having a CI user in the family affects the sibling's activities, emotions, and parental attention. Method Participants include 36 siblings with TH (M _age = 11.6 years) of CI users (M _age = 11.9 years) who completed quantitative measures of their perspectives of their brother/sister with CIs and the effect of hearing loss on themselves. Siblings with TH also could express their opinions via open-ended prompts. Results Overall, siblings with TH express positive perspectives of their brother/sister with CIs and report having a CI user in the family does not affect them much, particularly if the CI user has adequate communication skills. Responses to both quantitative and qualitative items converge on the close relationship between siblings but diverge relative to differential attention from parents (i.e., open-ended responses suggest parents spend more time with the CI user than the sibling with TH). Additionally, siblings acknowledge the presence of social communication deficits of the CI user in real-world situations. Conclusion This nuanced look at relationships among the parent, CI user, and sibling with TH highlights the importance of understanding the family system when working with children with hearing loss.

Hearing the Voice of a Shadow Child: Healthy Siblings Experience of Cystic Fibrosis and Other Life-Threatening Conditions

Cystic fibrosis (CF) is a chronic, life-threatening disease, similar to other chronic life-disrupting pediatric conditions, and this creates physical and psychosocial problems for parents and the healthy sibling/s of the sick child, who often become sibling carers. It is feared that, despite good intentions, professionals fail to hear the authentic voice of those intimately involved, especially these sibling carers, who can feel they became a “shadow child.” This study is a partnership between an academic and a former CF sibling carer, who wrote a “fairy story” for his children about the Uncle they never knew. It is an effort to hear the “voice of shadow children” who can feel left behind and unseen as families and professionals focus upon their ill sibling.

The impact of pediatric hematopoietic stem cell transplant timing and psychosocial factors on family and caregiver adjustment

BACKGROUND

The impact of pediatric hematopoietic stem cell transplant (HCT) on family functioning varies, but little is known about how the timing of HCT in children's treatment course contributes to this variability. This study examines how preexisting child, sibling, and family problems, the length of time between diagnosis to HCT, and children's age at HCT are associated with family and caregiver functioning.

PROCEDURE

Caregivers (n = 140) of children (≤18 years old) scheduled to undergo their first HCT completed the Psychological Assessment Tool-HCT and the Impact on Family Scale. Treatment information was extracted from electronic medical records. A bootstrapped multivariate path analysis was used to test the hypotheses.

RESULTS

More preexisting family problems related to greater caregiver perceived negative impact of their child's HCT across family and caregiver functioning domains. Less time between diagnosis and HCT was associated with greater caregiver personal strain, particularly for those with younger children undergoing HCT. Younger child age at HCT was also associated with a larger negative impact on family social functioning.

CONCLUSIONS

Families with preexisting problems are the most at-risk for experiencing negative impacts related to their child's HCT. The timing of a child's HCT within their treatment course and the child's age during HCT may impact families' social functioning and caregiver adjustment. Screening families for preexisting family problems, particularly for families with young children or who are abruptly learning of their child's need for an HCT, may assist providers in identifying families who would benefit from earlier or more intensive psychosocial support.

When Is Forgetting Not Forgetting? A Discursive Analysis of Differences in Forgetting Talk Between Adults With Cystic Fibrosis With Different Levels of Adherence to Nebulizer Treatments

Forgetting is often cited as a reason why people struggle to adhere to treatments for chronic conditions. Interventions have tried to improve forgetting behavior using reminders. We used a discursive psychological approach to explore differences in how high and low adherers constructed forgetting their nebulizer treatments for cystic fibrosis. Interviews were conducted with 18 adults from a cystic fibrosis center in the United Kingdom. High adherers constructed forgetting treatments as occasional lapses in automaticity and temporary lapses in memory that they found easy to repair. Low adherers utilized forgetting to normalize more consistent nonadherence to treatments. However, it is important to contextualize forgetting as a discursive resource that helped these participants to negotiate moral discourses around adherence to treatment that reminder interventions cannot address; we therefore recommend a more behavioral, patient-focused, theory-driven approach to intervention development.

Managing cystic fibrosis alongside children's schooling: Family, nurse and teacher perspectives

The treatment regimen for children with cystic fibrosis (CF) is vast and is usually undertaken in the family home. Managing CF coincides with other important family routines such as children's participation in education. There is a dearth of research that considers family routines that may influence, and be influenced by how CF is managed. To address this gap, this patient-led study examined how families manage CF alongside children's education in England. Semi-structured interviews were conducted with 14 participants comprising 5 children and young people with CF, 4 parents, 2 CF nurse specialists and 3 teachers. The results revealed that CF routines were organized to minimize disruption to education, although families experienced challenges in meeting all daily health and education demands. Families chose between children doing their treatments or participating in school activities when doing both were not feasible. Treatments were sometimes a barrier to education participation and children's learning. Families found treatment routines restrictive upon children's friendships. Education is a priority for families, which affects how they manage CF. CF clinical teams should consider bidirectional influences between important family routines and families' management of CF, when planning appropriate treatment regimens.

Well siblings of children with chronic illness: A synthesis research study

Well siblings of chronically ill children experience family disruptions that profoundly affect them. Previous research focusing on well siblings' experiences has often produced inconsistent findings, likely the result of varying study designs and samples. The purposes of this synthesis research study were twofold: (a) to assess the applicability of existing grounded theory of sibling response to a child's cancer to a wider range of childhood conditions; and (b) to refine the existing theory to reflect the experiences of the broader sample. Data for the synthesis came from a National Institute of Nursing Research-funded mixed-methods synthesis examining the intersection of childhood chronic illness and family life. The current analysis was based on well sibling results extracted from 78 research reports published between 2000 and 2014. An existing grounded theory, Creating a Tenuous Balance (CTB), was discovered at the outset of analysis and used as the primary framework for coding and synthesizing results. The focus of most studies was siblings' responses to 14 chronic conditions, with cancer being the most often studied. Results reflected siblings' perspectives of their experiences as well as perspectives of parents and the ill child. The analysis substantiated all four patterns of sibling behavior included in CTB, with the patterns of adapting to changes in personal and family life, and handling strong emotions being especially challenging aspects of the sibling experience. Moreover, the results expanded several aspects of CTB. The analysis provided evidence of the applicability of the theory to a varied group of chronic conditions and enabled us to identify important areas for developing interventions to support siblings.

Impact of Cystic Fibrosis on Unaffected Siblings: A Systematic Review

OBJECTIVE

To conduct a systematic review of the evidence to determine the impact of cystic fibrosis (CF) on unaffected siblings.

STUDY DESIGN

We searched MEDLINE (Ovid interface, from 1946); EMBASE (Ovid interface, from 1946); CINAHL (EBSCO interface); Academic Search Complete (EBSCO interface); Psych Info (EBSCO interface); ProQuest Theses' and Dissertation's (ProQuest); British Index of Nursing (ProQuest); Web of Science (ISI, Web of Knowledge portal); PubMed (PubMed NCBI); BASE (Bielefeld Academic Research Engine); Scopus; EThOS (e-theses online service); Open Grey; and Cochrane Library. Contents pages of the Journal of Cystic Fibrosis, June 2002-April 2017 were hand searched to identify further eligible studies. Reference lists of eligible articles and relevant review papers were screened. Inclusion criteria were full studies published after 1989 in English focusing on the impact of cystic fibrosis on unaffected siblings.

RESULTS

In total, 13 papers, 4 PhD theses and 1 MSc thesis were included in the review. Four themes were identified; family functioning, psychosocial impact, knowledge of CF, and condition-specific differences.

CONCLUSIONS

Most studies are old and may not accurately represent the impact of CF on unaffected siblings following changes to health care provision including newborn bloodspot screening and the advent of CF transmembrane regulator modulator therapies. Further work is needed directly with siblings rather than using mothers as proxies to determine effect of age, sex, and disease trajectory on unaffected siblings' experiences.

Adherence to medication in adults with Cystic Fibrosis: An investigation using objective adherence data and the Theoretical Domains Framework

OBJECTIVES

Adherence to nebulizer treatment in adults with Cystic Fibrosis (CF) is poor, and interventions are needed. This research aimed to identify the factors affecting nebulizer adherence using the Theoretical Domains Framework (TDF) and to compare these for participants with different levels of adherence.

DESIGN

Data-prompted interviews using the TDF.

METHODS

Eighteen semi-structured interviews were conducted with adults with CF during which objectively measured adherence data were discussed. Framework analysis was used to code the data into TDF domains, and inductive qualitative content analysis was used to code different beliefs and experiences. Aspects of the TDF that differed between participants with different adherence levels were explored.

RESULTS

Factors influencing adherence to treatment included all 14 domains of the TDF, 10 of which appeared to vary by adherence level: Skills; Memory and decision-making; and Behavioural regulation; Environmental context and resources; Social influences; Beliefs about consequences; Beliefs about capability; Reinforcement; Social role and identify; Intentions; Optimism; and Emotions.

CONCLUSIONS

This study is the first to use objectively measured adherence data in a data-prompted interview using the TDF framework to systematically assess the full range of factors potentially influencing adherence. The results highlighted that interventions need to consider issues of capability, opportunity, and motivation. Interventions that challenge dysfunctional beliefs about adherence and which support the development of routines or habits and problem-solving may be particularly useful for adults with CF. Statement of contribution What is already known? Adherence to medication in adults with cystic fibrosis is poor. Previous research has identified a range of contributing factors in relation to subjective reports of adherence. There is a wide discrepancy between self-reported adherence and objectively measured adherence. What this study adds A data-prompted interview using objectively measured adherence data enabled the systematic assessment of potential factors that could be targeted in an intervention to increase adherence. There were some differences in the factors that were identified by high and low adherers. There is not one-size fits all intervention for adherence to medication in cystic fibrosis.

Clinical Burdens of β-Thalassemia Major in Affected Children

BACKGROUND

β-thalassemia major (BTM) is an inherited blood disorder leading to severe anemia. A better understanding of BTM complications can be considered an important factor in developing effective health care provision.

METHOD

A descriptive exploratory design was used to identify the clinical burden of BTM from affected children's perspective. A convenience sample of 45 patients with BTM, accompanied by a family member, was recruited from a governmental hospital during April-May 2015.

RESULTS

The most reported clinical burden was facial deformity 86.9%, followed by systematic infection (48.8%), growth delay (44.4%), and liver problems (39.9%). Patient age was significantly associated with clinical burdens such as bone pain and facial deformity. The number of blood transfusions received was associated with growth delay and bone pain.

CONCLUSION

This study highlights the clinical burdens of thalassemia on affected children, in terms of physical appearance, growth delay and other burdens.

Illness Perceptions of Cystic Fibrosis: A Comparison of Young Adults with CF and Same-Aged Peers

In the last two decades, the life expectancy for individuals with Cystic Fibrosis (CF) has increased significantly. The limited research examining the psychosocial experiences of young adults with CF indicates that other young adults lack awareness and understanding of CF. Using the Illness Perception Questionnaire, perceptions of CF were examined in individuals with CF aged 16 to 25 and two groups of same-aged peers: those who did, or did not, know someone with CF. ANOVA with pairwise comparisons revealed that individuals with CF perceived significantly fewer physical symptoms of illness and fewer emotional and practical consequences of CF than both groups of peers. Individuals with CF also perceived significantly more personal control and greater understanding of CF than peers without experience of CF. Implications for enhancing opportunities for social engagement and for the provision of social support for young people with CF are identified.

Adherence to prophylaxis and quality of life in children and adolescents with severe haemophilia A

Treatment adherence in adolescents with chronic diseases is around 50%, and failure is more common in preventive therapy. In haemophilia, contradictory results are reported by the published studies. The objective of this study was to evaluate adherence with factor VIII (FVIII) prophylaxis in Spanish patients with severe haemophilia A between age 6 and 20 years. Data were collected retrosp-ectively in the previous 2 years. The primary endpoint was the absolute adherence index (AAI), and the endpoints were related to clinical status, age, prophylaxis regimen, responsibility for factor administration and quality of life (QoL), assessed by the Haemo-QoL questionnaires. A total of 78 patients from 14 Spanish hospitals were recruited. Adherence ranged between -64.4 and 66.7 (mean -3.08). No differences were observed between children and adolescents (7.11 vs. 6.39; P = 0.809). A statistically significant association (P < 0.010) between infra adherent group and target joint was found, as was a statistically significant difference (P < 0.010) between the number of bleeding episodes experienced by the adherent group (mean 1.4) and by infra adherents (mean 4.5). There was no significant difference between AAI and prophylactic regimen (6.35 vs. 6.96, P = 0.848), neither between AAI and the person responsible for factor administration (5.57 vs. 8.79, P = 0.326). The Haemo-QoL scores (8-12 years) were related to adherence level (P < 0.05). Adherence was approximately ideal and patients perceived a high QoL. Because of the repercussions for compliance, it is essential to work during puberty on emotional and self-acceptance aspects of the disease, as well as coping, and the patient's family, school and health team relationships.

Several siblings with Cystic Fibrosis as a risk factor for poor outcome

BACKGROUND

Occurrence of Cystic Fibrosis (CF) in more than one member in a family is not uncommon. The aim of our study was to assess the influence of multiple siblings with CF on disease expression and outcome.

METHODS

Study group consisted of 2-siblings (2-sibs, n = 42) or 3/4 siblings (3/4-sibs, n = 22) with CF in one family. Each sibling was matched by age, mutation, and gender to a single CF patient.

RESULTS

3/4-sibs subgroup compared to singles showed a lower mean FEV1 with a faster decline rate (58.4 ± 27.5 vs. 72.7 ± 25.4 and -5 ± 6.4 vs. -1.7 ± 2.8 %predicted decline/year respectively, p < .05), more airway colonization by Pseudomonas aeruginosa and Mycobacterium abscessus (15 (68%) vs. 8 (36%) and 7 (32%) vs. 4 (18%), respectively, p < .05) and more lung transplants (5 (23%) vs. 2 (9%), respectively, p < .02). Last mean FEV1 within 3/4-sibs was significantly lower for the youngest sib (p < .05).

CONCLUSIONS

Three or more CF patients in one family may be a risk factor for more severe disease and poor prognosis. In our view this reflects the burden of disease on the patients and families.

Treatment non-adherence in pediatric long-term medical conditions: systematic review and synthesis of qualitative studies of caregivers' views

Background

Non-adherence to prescribed treatments is the primary cause of treatment failure in pediatric long-term conditions. Greater understanding of parents and caregivers’ reasons for non-adherence can help to address this problem and improve outcomes for children with long-term conditions.

Methods

We carried out a systematic review and thematic synthesis of qualitative studies. Medline, Embase, Cinahl and PsycInfo were searched for relevant studies published in English and German between 1996 and 2011. Papers were included if they contained qualitative data, for example from interviews or focus groups, reporting the views of parents and caregivers of children with a range of long-term conditions on their treatment adherence. Papers were quality assessed and analysed using thematic synthesis.

Results

Nineteen papers were included reporting 17 studies with caregivers from 423 households in five countries. Long-term conditions included; asthma, cystic fibrosis, HIV, diabetes and juvenile arthritis. Across all conditions caregivers were making on-going attempts to balance competing concerns about the treatment (such as perceived effectiveness or fear of side effects) with the condition itself (for instance perceived long-term threat to child). Although the barriers to implementing treatment regimens varied across the different conditions (including complexity and time-consuming nature of treatments, un-palatability and side-effects of medications), it was clear that caregivers worked hard to overcome these day-to-day challenges and to deal with child resistance to treatments. Yet, carers reported that strict treatment adherence, which is expected by health professionals, could threaten their priorities around preserving family relationships and providing a ‘normal life’ for their child and any siblings.

Conclusions

Treatment adherence in long-term pediatric conditions is a complex issue which needs to be seen in the context of caregivers balancing the everyday needs of the child within everyday family life. Health professionals may be able to help caregivers respond positively to the challenge of treatment adherence for long-term conditions by simplifying treatment regimens to minimise impact on family life and being aware of difficulties around child resistance and supportive of strategies to attempt to overcome this. Caregivers would also welcome help with communicating with children about treatment goals.

Pediatric chronic illness (cancer, cystic fibrosis) effects on well siblings: parents' voices

This study is a secondary analysis of data gathered during baseline data collection prior to a cognitive-psychosocial-respite intervention provided in a randomized controlled trial (RCT). Content analysis was used to identify themes in parents' responses to an open-ended item about their perceptions of the effects on siblings of having a brother or sister who has either cancer or cystic fibrosis (CF). Of 91 themes tallied in the cancer group (n = 29), 74.5% reflected negative manifestations of increased risk in siblings, 1.1% no risk; and 24.2%, positive outcomes. Of 53 themes tallied in the CF group (n = 15), the same three categories had 67.9 %, 0%, and 32.1%, respectively. Contemporary life in these families portrayed in parents' descriptions not only validate the rationale for the RCT done, but also suggest the need in ambulatory pediatrics for intervention research on these vulnerable populations.

The experiences of Latino siblings of children with developmental disabilities

OBJECTIVE

This qualitative study explored the experiences of Latino siblings of children with developmental disabilities.

METHODS

Parents and typically developing siblings from 15 Latino families with a child with a developmental disability participated in separate interviews.

RESULTS

Using consensual qualitative research methodology, domains reflecting siblings' relationships, emotional experiences and communication about the disability were identified. The child's need for caregiving was a prominent topic in the sibling and parent narratives. Parents reported concerns about siblings' experience of differential treatment, whereas siblings reported concerns about restricted social activities because of their brother/sister.

CONCLUSIONS

Including multiple informants revealed commonalities and differences in parents' and siblings' perspectives on the impact of a child's disability. The importance of considering sibling adaptation in sociocultural context is discussed.

Supporting cystic fibrosis disease management during adolescence: the role of family and friends

BACKGROUND

Successful management of a complex disease, such as cystic fibrosis (CF), requires support from family and friends; however, few studies have examined social support in adolescents with CF.

METHODS

Twenty-four adolescents were interviewed about the support they receive from family and friends. Interviews were transcribed, coded and analysed to determine the types, frequency and perceived supportiveness of specific behaviours.

RESULTS

Both family and friends provided treatment-related support to adolescents with CF. Family provided more tangible support and friends provided more relational support. Adolescents also reported that the manner, timing and context of support behaviours influenced their perceptions of the behaviours' supportiveness. A subset of adolescents (17%) chose not to disclose their diagnosis to their friends.

CONCLUSIONS

The provision of support appears to be distinct from adolescent's perception of support and there may be some behaviours, such as treatment reminders, that are important to disease management but viewed as less supportive by adolescents. Facilitating increased social support holds the promise of improving disease management during adolescents, but more work is need to understand which aspects of support are related to management outcomes.

"This is the best fatal illness that you can have": contrasting and comparing the experiences of parenting youth with cystic fibrosis and congenital heart disease

Despite the important instrumental and emotional role that parents play in the lives of children with cystic fibrosis (CF) and congenital heart disease (CHD), qualitative researchers have not examined the similarities and differences between caregivers' experiences. Informed by thematic analysis, in this qualitative study I explored what it is like to care for a child with a chronic illness from the perspective of CF and CHD parents at a children's hospital in Canada. Pediatric caregiver stress was qualitatively different between CF and CHD parents, whereas temporal dilemmas were unique sources of stress for CF parents only. To alleviate stress, all parents drew on a three-way, interrelated process to comprehend their child's illness and acquire perspective. By opening up the social worlds of parents, I illuminate important similarities and differences in the caregiving experience of parents of youth with CF and CHD, and offer novel contributions to the literature.

Unravelling complexities involved in parenting a child with cystic fibrosis: an interpretative phenomenological analysis

We conducted a qualitative study with caregivers for a contemporary understanding of the challenge of caring for a child with cystic fibrosis (CF). A single case is presented that details one woman's experience from her unique perspective of both, 'mother to a child with CF' and 'CF healthcare provider' using an interpretative phenomenological analysis. Emergent themes include: 'trying to keep things normal,' which includes different types of normality and routine management of treatment; 'when things become difficult,' which includes dealing with symptoms and battling with CF related decline; and, 'the complexity of decision making.' The discussion section expands on how, for this mother contrasting modes of managing CF (everyday life/full-on alert) co-existed and were further complicated by (i) role discrepancies (mother/nurse), and (ii) a dialectic between affect and reason. The CF parenting challenge increasingly involves responsibility for complex healthcare interventions and this study suggests a need for further enquiry into how caregivers are involved in the treatment plan and decision-making about treatment. Practice implications are proposed.

Caring for a child with cystic fibrosis: the children's nurse's role

This article presents a narrative literature review of the psychosocial impact on family life of caring for a child diagnosed with cystic fibrosis. Diagnosis of long-term illness in a child causes major upheaval in the lives of both the child and family. Normal family life is often emotionally, socially, physically and financially disrupted. Amid such disruption, parents attempt to cope by creating a semblance of order in their lifestyle. Within an interdisciplinary approach to caring, the children's nurse plays a pivotal role in supporting families to establish such order and reconstruct their lives, while coming to terms with the knowledge that their child could die prematurely. In addition, the nurse, in his/her role as teacher and educator, empowers parents, children and young people with the knowledge to make informed decisions and assists parents in developing the skills (often technical) to care for their child. Cystic fibrosis is one such condition in childhood, and this article explores the main psychosocial issues experienced by families caring for their child following diagnosis of CF, as raised in the literature.

Self-care and cystic fibrosis: a review of research with adults

The issue of self-care is becoming increasingly central to both policy and practice in health and social care in the community. It is imperative therefore that research in this important area is drawn together and presented coherently so as to ensure that change can be informed by evidence and implemented sensitively. As cystic fibrosis (CF) has until recently been regarded as a paediatric condition, there is relatively little research that focuses on the self-care of adults. Although not entirely uncritical of traditional biomedicine, these studies focus on individual patient deficits and are directed primarily at facilitating their 'compliance'. After discussing some important methodological, evidential and theoretical limitations of this research, other recent CF literature will be considered that suggests the possibility of developing a 'social model' for self-care research. The proposed model is more pluralistic and less prescriptive than its predecessors and the resulting 'types' of self-care indicate that both old and new, mainstream and marginal discourses should co-exist. Indeed, recognising the legitimacy of distinct varieties of self-care not only guards against unwarranted moralising and pathologising but may also enable self-care support to be negotiated and tailored more appropriately.

The experience of siblings of adolescents with eating disorders

PURPOSE

To qualitatively and quantitatively explore the experience and QOL of siblings of AEDs. To date, there is little research on the quality of life (QOL) and the effect an eating disorder (ED) has on the siblings of adolescents with an eating disorder (AEDs).

METHODS

Siblings were recruited between January 2008 and April 2008. Inclusion criteria included siblings aged 10-18 years old and living with a sibling with an ED. Exclusion criteria included having an ED, or major psychiatric disorder, or a communication problem that interfered with their participation. Siblings completed a general assessment questionnaire, the Pediatric Quality of Life inventory 4.0 Generic Core Scales and Eating Attitudes Test-26 (EAT-26). Focus group interviews were conducted until saturation was achieved and thematic analysis was employed.

RESULTS

Twenty siblings (14 females) of 17 AEDs (15 females) participated. All but one sibling scored within the normal range for the Eating Attitudes Test-26. Key themes identified included a desire to understand the ED, acute awareness of ED behaviors and thoughts, challenges in understanding noneating-related obsessive behaviors, increase in family conflict and arguments, compassion and concern for the AED, feelings of loss and sacrifice, overwhelming sense of responsibility for the AED, and a sense of pervasiveness of the ED in all aspects of their lives. The siblings' accounts of these themes were noted to be fraught with contradictions. Eighty percent reported that their QOL was negatively affected by the onset of their siblings' ED.

CONCLUSION

Clinical attention and further research into the experience of siblings of adolescents with ED is needed.

"All at sea": the experience of living with cystic fibrosis

In this qualitative study the researchers explored living with cystic fibrosis (CF)-a chronic, life-threatening, life-limiting disease that demands a relentless regime of daily treatment. The unique challenges and issue for care that CF presents were considered. Utilizing a phenomenological perspective, data drawn from unstructured interviews included narratives and drawings contributed by children, adolescents, young adults, and parents-eight families representing nine young people with CF. In line with van Manen's approach, four existentials were used to consider a lifeworld in which notions of time, body, space, and relationship are indelibly altered. From original fright, through ongoing dynamics of fear, fight, flight, form, familiarity, and philosophy, people with CF pursue a future that is threatened and continually redefined. As a result of enhanced understanding, care can be delivered from an empathetic bearing toward those for whom it is not so much a bothersome routine, but a life-and-death imperative.

Problems and solutions: Accounts by parents and children of adhering to chest physiotherapy for cystic fibrosis

PURPOSE

Although chest physiotherapy is central to the management of cystic fibrosis (CF), adherence among children is problematic. This study explores accounts by parents and children of the difficulties of adhering to chest physiotherapy for cystic fibrosis, and identifies strategies used by families to overcome these.

METHODS

A qualitative study based on in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7 - 17 years, and with 31 parents.

RESULTS

Physiotherapy was frequently described as restrictive, threatening to identity and boring, giving rise to feelings of unfairness, inequality, 'difference', and social stigma. Motivation to adhere was influenced by perceptions of effectiveness that depended on external signs evident during or after the physiotherapy. Motivation was enhanced where parents and children visualized the accumulation of mucus. Some parents had developed distraction techniques that improved the experience of chest physiotherapy but had few opportunities to share these with other parents.

CONCLUSION

The experience of physiotherapy is problematic to some parents and children. Furthermore, motivation to overcome these problems may be undermined by perceptions of ineffectiveness. Distraction techniques that change the value that the child places on the time spent doing physiotherapy and that reduces their perception of its duration may improve experience and adherence. The potential of visualization techniques to promote adherence should be investigated further.

Adherence to treatment in adolescents with cystic fibrosis: the role of illness perceptions and treatment beliefs

OBJECTIVES

This study was conducted to explore the relationships between illness perceptions, emotional representations, treatment beliefs and reported adherence in adolescents with cystic fibrosis (CF).

METHODS

Thirty-eight adolescents completed questionnaires assessing their perceptions of CF, beliefs about prescribed treatments and reported adherence to chest physiotherapy, enzyme supplements, and antibiotics.

RESULTS

Reported non-adherence to chest physiotherapy was associated with the way in which patients judged their personal need for treatment relative to their concerns about potential adverse effects. Patients reported strong doubts about the necessity of chest physiotherapy. Reported non-adherence to antibiotics was related to doubts about the necessity of antibiotics, believing that CF is not amenable to treatment control. Despite these beliefs about treatment, participants perceived CF as a chronic condition.

CONCLUSIONS

The findings provide preliminary support for the self-regulatory model, using the necessity-concerns framework to operationalize treatment beliefs, in explaining adherence to treatment in adolescents with CF.

Through a mother's lens: a qualitative analysis reveals how temporal experience shifts when a boy born preterm has cystic fibrosis

We present a qualitative case study of one woman's experience of bringing up a child with cystic fibrosis (CF), born prematurely, using interpretative phenomenological analysis (IPA). This mother's existential account portrays time sequences for developmental milestones and synchronization of lifecycle events as atypical. Her perception of her child fluctuated radically; illness seemed to displace time, which collapsed with adversity. The temporal relations of CF and preterm birth are blurred at certain points. Although the challenge of compromised health may in some ways have promoted her son's development, his immature self-expression moved this mother towards an insider perspective of his experience. Cystic fibrosis is an ominous presence that demands respect even when the child is well. Anticipating the psychological impact of biomedical interventions can help to minimize trauma and maximize adaptation. Talking and play at transitional time points may assist the way parents and children assimilate temporal disruptions.

Self-reported involvement of family members in the care of adults with CF

BACKGROUND

Few empirical studies have examined the role of family caregivers in the lives of adults with CF.

METHODS

As part of the Project on Adult Care in CF (PAC-CF), an on-going prospective, longitudinal panel study of adults with CF, 119 family members and friends of adults with CF completed a mail survey in which they reported the frequency of help they provide for their family member with CF during routine care, hospitalization, and home IV treatment.

RESULTS

The 119 caregivers were mainly spouses or unmarried partners (56%) and parents (29%). Fifteen percent of caregivers were children, friends, siblings or roommates. Family caregivers for adults with CF report assisting mainly with communication and social support during routine treatment, although one third provide some clinical care on a regular basis. Family caregivers report an increase in assistance during periods of acute illness, such as during a hospitalization and home IV treatment, especially with clinical care tasks.

CONCLUSIONS

The depth of commitment required of families of children with CF has been well documented for decades. Our results suggest that the responsibilities of family members diminish only moderately as those with CF reach adulthood.

From child to adult: An exploration of shifting family roles and responsibilities in managing physiotherapy for cystic fibrosis

Although chest physiotherapy is central to the management of cystic fibrosis many report problems with adherence. Research in other long-term conditions suggests that non-adherence may be exacerbated as the child grows older and self-care responsibilities are transferred to the young person. We explored the nature and variation in roles of family members, how responsibility was transferred from the parent/family to the child, and what factors aided or hindered this process. We conducted in-depth interviews with 32 children with a diagnosis of cystic fibrosis aged 7-17 years, and with 31 parents attending cystic fibrosis clinics in two Scottish regions. Family responsibilities were primarily focused on mothers. The level and nature of involvement varied along a continuum that separated into six parental and five child roles and changed over time. However, this movement was frequently reversed during periods of illness or mistrust. The day to day experience of such a transfer was not straightforward, linear or unproblematic for any of the family members. Three factors were identified as assisting the transfer of responsibility: parents' perceptions of the benefits of transferring responsibility, children's perceptions of the benefits, and the available physical, social and psychological resources to support such a transfer. The principles and lessons from "concordance" (a therapeutic alliance based on a negotiation between equals and which may lead to agreement on management or agreement to differ) may provide a foundation for newly developing relationships between parents and their children emerging into adulthood. Further research is required to develop more specifically the content and structure of required support, its effectiveness in achieving more concordant relationships, and the resulting impact on adherence, perceived health and well-being from the perspective of the young person and parent.

Looking after well siblings of adolescent girls with anorexia: an important parental role

BACKGROUND

Research has suggested that well siblings of children with chronic and life-threatening illnesses are at risk for negative outcomes and that parents' responses to the illnesses can influence the adaptation of well siblings. Yet, parents' efforts to look after well siblings in the context of illness are rarely considered in literature about sibling adaptation. The importance of attending to the needs of well siblings was a major theme to emerge from a qualitative analysis of the experiences of parents of adolescent girls with anorexia nervosa.

METHODS

In-depth interviews were conducted with 24 parents of adolescent girls with anorexia and analysed using grounded theory method.

RESULTS

The data indicated that parents viewed caring for well siblings in the context of anorexia as an important role and responsibility. Parents reported making conscious and active efforts to look after well siblings by: maintaining normality; compensating for changes to routines; protecting siblings; providing emotional support; and managing the consequences.

CONCLUSIONS

This paper provides a picture of the actions parents take to help well siblings adapt to anorexia in the family. Further research is needed to develop and expand this understanding to families experiencing a wide range of chronic and life-threatening illnesses. The findings underline the importance of clinical attention and further research into the critical parental role of caring for well siblings.

Family structure and mothers' caregiving of children with cystic fibrosis

The purpose of this investigation is to examine differences in the experiences of mothers of children with cystic fibrosis who are in diverse family structures (first-marriage families, stepfamily households, single-parent households). In particular, mothers' perceptions of children's health, adherence to prescribed treatments, and help received from others were compared and predictors of treatment adherence were examined. Children's health and adherence to treatment regimens were not related to family structure. Mothers had the major responsibility for seeing that cystic fibrosis treatments were followed, regardless of family structure. Single mothers received less help than married and repartnered mothers. Married fathers helped with treatments more than nonresidential divorced fathers and stepfathers. Implications for nursing practice and suggestions for future research are offered.