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Li W, Su M, Zhang W, Fan X, Li R, Gao Y, Wei X. Barriers and facilitators of implementing electronic monitors to improve adherence and health outcomes in tuberculosis patients: protocol for a systematic review based on the Consolidated Framework for Implementation Research. Health Res Policy Syst 2023; 21:115. [PMID: 37915089 PMCID: PMC10621129 DOI: 10.1186/s12961-023-01054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Tuberculosis (TB) has been regarded as 'a relentless scourge', increasing morbidity and mortality and burdening vulnerable populations. Poor adherence to TB treatment and ineffective traditional interventions hinders TB control. A novel TB approach called 'electronic monitors', equipping medication boxes with daily audio or visual reminders for electronically monitoring medication intake, seems promising in improving adherence and health outcomes and overcoming the weaknesses of traditional interventions. However, no review has systematically examined and synthesized the influencing factors of implementing electronic monitors. Implementation research offers the means to analyse the influencing factors of the implementation and its process, fitting well with the aim of this review. Therefore, the widely recognized Consolidated Framework for Implementation Research (CFIR), which offers a common taxonomy for evaluating intervention implementation, will be adopted to systematically identify barriers and facilitators of the electronic monitors for improving adherence and health outcomes in patients with TB. METHODS AND ANALYSIS The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Literature research will be conducted in five electronic databases (Ovid MEDLINE, CINAHL, EMBASE, Cochrane Library and Web of Science) to identify the barriers and facilitators of implementing electronic monitors in patients with TB. The CFIR will be used as a guide for categorizing and synthesizing the barriers and facilitators. Study screening, data extraction, quality appraisal and data analysis will be conducted by two independent reviewers. The use of additional reviewers will solve any disagreements between the two reviewers. DISCUSSION Given the increased prominence of TB epidemiology and the adherence problem of electronic monitors, there is a solid rationale for synthesizing the existing studies via the CFIR. The findings and conclusion of this review will lay bare the achievements and effectiveness of implementing electronic monitors, as well as the attendant gaps and limitations. Further strategies for facilitating the implementation of electronic monitors will also be explored. This review will be of essential significance for research and practice, supporting future academic research initiatives centred on patients with TB and aiding electronic monitor design in lowering the morbidity and mortality associated with TB disease. TRIAL REGISTRATION NUMBER PROSPERO: CRD42023395747.
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Affiliation(s)
- Wenhui Li
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China.
| | - Weile Zhang
- School of Public Administration, Inner Mongolia University, Hohhot, China
| | - Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China
| | - Renzhong Li
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yulong Gao
- Inner Mongolia Center for Disease Control and Prevention, Hohhot, China
| | - Xiaolin Wei
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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van de Hei SJ, Stoker N, Flokstra-de Blok BMJ, Poot CC, Meijer E, Postma MJ, Chavannes NH, Kocks JWH, van Boven JFM. Anticipated barriers and facilitators for implementing smart inhalers in asthma medication adherence management. NPJ Prim Care Respir Med 2023; 33:22. [PMID: 37208358 DOI: 10.1038/s41533-023-00343-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 05/05/2023] [Indexed: 05/21/2023] Open
Abstract
Smart inhalers are electronic monitoring devices which are promising in increasing medication adherence and maintaining asthma control. A multi-stakeholder capacity and needs assessment is recommended prior to implementation in healthcare systems. This study aimed to explore perceptions of stakeholders and to identify anticipated facilitators and barriers associated with the implementation of smart digital inhalers in the Dutch healthcare system. Data were collected through focus group discussions with female patients with asthma (n = 9) and healthcare professionals (n = 7) and through individual semi-structured interviews with policy makers (n = 4) and smart inhaler developers (n = 4). Data were analysed using the Framework method. Five themes were identified: (i) perceived benefits, (ii) usability, (iii) feasibility, (iv) payment and reimbursement, and (v) data safety and ownership. In total, 14 barriers and 32 facilitators were found among all stakeholders. The results of this study could contribute to the design of a tailored implementation strategy for smart inhalers in daily practice.
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Affiliation(s)
- Susanne J van de Hei
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Bertine M J Flokstra-de Blok
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
- General Practitioners Research Institute, Groningen, the Netherlands
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Charlotte C Poot
- Department of Primary Care and Public Health, Leiden University Medical Center, Leiden, The Netherlands
- National eHealth Living Lab, Leiden, The Netherlands
| | - Eline Meijer
- Department of Primary Care and Public Health, Leiden University Medical Center, Leiden, The Netherlands
- National eHealth Living Lab, Leiden, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Niels H Chavannes
- Department of Primary Care and Public Health, Leiden University Medical Center, Leiden, The Netherlands
- National eHealth Living Lab, Leiden, The Netherlands
| | - Janwillem W H Kocks
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands
- General Practitioners Research Institute, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Medication Adherence Expertise Center of the northern Netherlands (MAECON), Groningen, The Netherlands
| | - Job F M van Boven
- Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, The Netherlands.
- Medication Adherence Expertise Center of the northern Netherlands (MAECON), Groningen, The Netherlands.
- Department of Clinical Pharmacy & Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
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Clinical Impact of Electronic Monitoring Devices of Inhalers in Adults with Asthma or COPD: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2023; 16:ph16030414. [PMID: 36986513 PMCID: PMC10055893 DOI: 10.3390/ph16030414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023] Open
Abstract
We conducted a systematic review and meta-analysis to gain insight into the characteristics and clinical impact of electronic monitoring devices of inhalers (EMDs) and their clinical interventions in adult patients with asthma or COPD. The search included PubMed, Web of Science, Cochrane, Scopus and Embase databases, as well as official EMDs websites. We found eight observational studies and ten clinical trials, assessing a wide range of clinical outcomes. Results from the meta-analysis on adherence to inhalers in a period over three months were favourable in the EMD group (fixed effects model: SMD: 0.36 [0.25–0.48]; random effects model SMD: 0.41 [0.22–0.60]). An exploratory meta-analysis found an improvement in ACT score (fixed effect model SMD: 0.25 [0.11–0.39]; random effects model: SMD: 0.47 [−0.14–1.08]). Other clinical outcomes showed mixed results in the descriptive analyses. The findings of this review highlight the benefits of EMDs in the optimization of adherence to inhaled therapy as well as the potential interest in other clinical outcomes.
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Lawrie L, Turner S, Cotton SC, Wood J, Morgan HM. A qualitative process evaluation within a clinical trial that used healthcare technologies for children with asthma-insights and implications. PLoS One 2023; 18:e0280086. [PMID: 36603013 PMCID: PMC9815588 DOI: 10.1371/journal.pone.0280086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Healthcare technologies are becoming more commonplace, however clinical and patient perspectives regarding the use of technology in the management of childhood asthma have yet to be investigated. Within a clinical trial of asthma management in children, we conducted a qualitative process evaluation that provided insights into the experiences and perspectives of healthcare staff and families on (i) the use of smart inhalers to monitor medication adherence and (ii) the use of algorithm generated treatment recommendations. METHODS We interviewed trial staff (n = 15) and families (n = 6) who were involved in the trial to gauge perspectives around the use of smart inhalers to monitor adherence and the algorithm to guide clinical decision making. FINDINGS Staff and families indicated that there were technical issues associated with the smart inhalers. While staff suggested that the smart inhalers were good for monitoring adherence and enabling communication regarding medication use, parents and children indicated that smart inhaler use increased motivation to adhere to medication and provided the patient (child) with a sense of responsibility for the management of their asthma. Staff were open-minded about the use of the algorithm to guide treatment recommendations, but some were not familiar with its' use in clinical care. There were some concerns expressed regarding treatment step-down decisions generated by the algorithm, and some staff highlighted the importance of using clinical judgement. Families perceived the algorithm to be a useful technology, but indicated that they felt comforted by the clinicians' own judgements. CONCLUSION The use of technology and individual data within appointments was considered useful to both staff and families: closer monitoring and the educational impacts were especially highlighted. Utilising an algorithm was broadly acceptable, with caveats around clinicians using the recommendations as a guide only and wariness around extreme step-ups/downs considering contextual factors not taken into account.
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Affiliation(s)
- Louisa Lawrie
- Health Services Research Unit, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Stephen Turner
- Royal Aberdeen Children’s Hospital, University of Aberdeen, Aberdeen, United Kingdom
| | - Seonaidh C. Cotton
- Health Services Research Unit, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Jessica Wood
- Health Services Research Unit, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Heather M. Morgan
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
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Bosnic-Anticevich S, Bakerly ND, Chrystyn H, Hew M, van der Palen J. Advancing Digital Solutions to Overcome Longstanding Barriers in Asthma and COPD Management. Patient Prefer Adherence 2023; 17:259-272. [PMID: 36741814 PMCID: PMC9891071 DOI: 10.2147/ppa.s385857] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/09/2022] [Indexed: 01/30/2023] Open
Abstract
Maintenance therapy delivered via inhaler is central to asthma and chronic obstructive pulmonary disease (COPD) management. Poor adherence to inhaled medication and errors in inhalation technique have long represented major barriers to the optimal management of these chronic conditions. Technological innovations may provide a means of overcoming these barriers. This narrative review examines ongoing advances in digital technologies relevant to asthma and COPD with the potential to inform clinical decision-making and improve patient care. Digital inhaler devices linked to mobile apps can help bring about changes in patients' behaviors and attitudes towards disease management, particularly when they build in elements of interactivity and gamification. They can also support ongoing technique education, empowering patients and helping providers maximize the value of consultations and develop effective action plans informed by insights into the patient's inhaler use patterns and their respiratory health. When combined with innovative techniques such as machine learning, digital devices have the potential to predict exacerbations and prompt pre-emptive intervention. Finally, digital devices may support an advanced precision medicine approach to respiratory disease management and help support shared decision-making. Further work is needed to increase uptake of digital devices and integrate their use into care pathways before their full potential in personalized asthma and COPD management can be realized.
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Affiliation(s)
- Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
- Correspondence: Sinthia Bosnic-Anticevich, Woolcock Institute of Medical Research, 431 Glebe Point Road, Glebe, 2037, NSW, Australia, Tel +61 414 015 614, Email
| | - Nawar Diar Bakerly
- Manchester Metropolitan University, Manchester, United Kingdom, Salford Royal NHS Foundation Trust, Manchester, UK
| | | | - Mark Hew
- Allergy, Asthma, and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands, and Section Cognition, Data and Education, University of Twente, Enschede, the Netherlands
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Mosnaim GS, Greiwe J, Jariwala SP, Pleasants R, Merchant R. Digital Inhalers and Remote Patient Monitoring for Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2525-2533. [PMID: 35779779 DOI: 10.1016/j.jaip.2022.06.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/27/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
Digital inhaler systems, remote patient monitoring, and remote therapeutic monitoring offer great promise as diagnostic tools and therapeutic interventions to improve adherence and inhaler technique for patients with difficult-to-control asthma. In turn, improvements in adherence and inhaler technique may translate into decreasing the need for high side effect treatments such as oral corticosteroids and costly therapies including biologics. Although more clinical trials are needed, studies that use digital inhaler systems to collect objective real-time data on medication-taking behavior via electronic medication monitors and feed this data back to patients on their mobile asthma app, and to health care professionals on the clinician dashboard to counsel patients, show positive outcomes. This article addresses the use of these diagnostic and therapeutic tools in asthma care, how to choose a digital inhaler system, how to teach patients to use the system, strategies for the adoption of these technologies in large health care systems as well as smaller practices, coding and reimbursement, liability concerns, and research gaps.
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Affiliation(s)
- Giselle S Mosnaim
- Division of Allergy, Asthma and Immunology, Department of Medicine, NorthShore University HealthSystem, Evanston, Ill.
| | - Justin Greiwe
- Bernstein Allergy Group, Inc, Cincinnati, Ohio; Division of Immunology/Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sunit P Jariwala
- Division of Allergy/Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Roy Pleasants
- Department of Medicine, Duke School of Medicine, Raleigh, NC
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Nardell MF, Lee YS, Rousseau E, Julies R, Klaas P, Vundhla P, Butler L, Bassett IV, Mellins CA, Bekker LG, Katz IT. "You are not alone": a qualitative study to explore barriers to ART initiation and implications for a proposed community-based youth treatment club among young adults newly diagnosed with HIV in South Africa. AIDS Care 2021; 33:952-961. [PMID: 33345593 PMCID: PMC8215080 DOI: 10.1080/09540121.2020.1861179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
In South Africa, despite universal antiretroviral therapy (ART) availability, 60% of persons living with HIV (PLWH) ages 15-24 are not on treatment. This qualitative study aimed to identify barriers to ART initiation and the implications for a proposed community-based Youth Treatment Club to improve ART initiation for young PLWH in limited-resource, high HIV-prevalence communities in Cape Town, South Africa. Recruiting participants at community testing sites from 2018 to 2019, we conducted semi-structured interviews, informed by Social Action Theory (SAT), with 20 young adults, ages 18- to 24-years-old, newly diagnosed with HIV, along with 10 healthcare providers. Through systematic qualitative analysis, we found that young PLWH face barriers to treatment initiation in three SAT domains: (1) stigmatizing social norms (social regulation processes); (2) challenges coping with a new diagnosis (self-regulation processes); and (3) anticipated stigma in the clinic environment (contextual factors). Participants shared that a proposed community-based Youth Treatment Club for newly diagnosed youth would be an acceptable strategy to promote ART initiation. They emphasized that it should include supportive peers, trained facilitator support for counseling and education, and a youth-friendly environment.
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Affiliation(s)
- Maria F. Nardell
- Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yeonsoo Sara Lee
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
| | - Elzette Rousseau
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Robin Julies
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Portia Klaas
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Prisca Vundhla
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
| | - Lisa Butler
- Institute for Collaboration on Health, Intervention and Policy, University of Connecticut, Storrs, CT, USA
| | - Ingrid V. Bassett
- Harvard Medical School, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA
| | - Linda-Gail Bekker
- The Desmond Tutu Health Foundation, University of Cape Town, Cape Town, Republic of South Africa
- Institute of Infectious Disease and Molecular Medicine, Department of Medicine, University of Cape Town, Cape Town, Republic of South Africa
- Governing Council, International AIDS Society, Geneva, Switzerland
| | - Ingrid T. Katz
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Harvard Global Health Institute, Harvard University, Cambridge, MA, USA
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Kan K, Shaunfield S, Kanaley M, Chadha A, Boon K, Foster CC, Morales L, Labellarte P, Vojta D, Gupta RS. Parent Experiences With Electronic Medication Monitoring in Pediatric Asthma Management: Qualitative Study. JMIR Pediatr Parent 2021; 4:e25811. [PMID: 33890861 PMCID: PMC8105758 DOI: 10.2196/25811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Electronic medication monitoring (EMM) is a digital tool that can be used for tracking daily medication use. Previous studies of EMM in asthma management have been conducted in adults or have examined pediatric interventions that use EMM for less than 1 year. To understand how to improve EMM-enhanced interventions, it is necessary to explore the experiences of parents of children with asthma, recruited from outpatient practices, who completed a 12-month intervention trial. OBJECTIVE The objective of our study was to use qualitative inquiry to answer the following questions: (1) how did using an EMM-enhanced intervention change parents'/caregivers' experiences of managing their child's asthma, and (2) what do parents recommend for improving the intervention in the future? METHODS Parents were recruited from the intervention arm of a multicomponent health intervention enhanced by Bluetooth-enabled sensors placed on inhaler medications. Semistructured interviews were conducted with 20 parents of children aged 4-12 years with asthma. Interviews were audio-recorded, transcribed, and inductively analyzed using a constant comparative approach. RESULTS Interview participants reflected an even mix of publicly and privately insured children and a diverse racial-ethnic demographic. Parents discussed 6 key themes related to their experience with the EMM-enhanced intervention for the management of their child's asthma: (1) compatibility with the family's lifestyle, (2) impact on asthma management, (3) impact on the child's health, (4) emotional impact of the intervention, (5) child's engagement in asthma management with the intervention, and (6) recommendations for future intervention design. Overall, parents reported that the 12-month EMM intervention was compatible with their daily lives, positively influenced their preventive and acute asthma management, and promoted their child's engagement in their own asthma management. While parents found the intervention acceptable and generally favorable, some parents identified compatibility issues for families with multiple caregivers and frustration when the technology malfunctioned. CONCLUSIONS Parents generally viewed the intervention as a positive influence on the management of their child's asthma. However, our study also highlighted technology challenges related to having multiple caregivers, which will need to be addressed in future iterations for families. Attention must be paid to the needs of parents from low socioeconomic households, who may have more limited access to reliable internet or depend on other relatives for childcare. Understanding these family factors will help refine how a digital tool can be adopted into daily disease management of pediatric asthma.
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Affiliation(s)
- Kristin Kan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sara Shaunfield
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Madeleine Kanaley
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Avneet Chadha
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Kathy Boon
- Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Carolyn C Foster
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Luis Morales
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Patricia Labellarte
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Deneen Vojta
- UnitedHealth Group, Minnetonka, MN, United States
| | - Ruchi S Gupta
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.,Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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