Treatment adherence in paediatric inflammatory bowel disease: perceptions from adolescent patients and their families

Utilizing a multisystemic model of resilience to synthesize research in youth with inflammatory bowel disease: a narrative review

Background and Objective

The study of resilience in youth with inflammatory bowel disease (IBD) is in early stages. The current review aims to illustrate how the use of a multisystemic framework may serve as a developmental and disease-appropriate framework for conceptualizing and designing resilience research for youth with IBD.

Methods

This is a narrative review; therefore, a comprehensive and systematic literature search was not conducted. Rather, the current paper aims to map selected existing literature to a multisystemic model as exemplars of how the model may be used in youth with IBD. Relevant literature was reviewed, synthesized, and mapped onto the proposed multi-systemic framework.

Key Content and Findings

The current review considers existing literature across three proposed dimensions of resilience: contexts of risk exposure, protective and promotive factors/processes, and desired outcomes. Review of each dimension includes consideration of selected existing literature to explain what is known about each dimension currently, as well as to propose additional potential future areas to broaden understanding. Specific key takeaways include: (I) understanding risk exposure in young people with IBD requires consideration of disease-specific, demographic, and sociocultural factors; (II) protective and promotive factors and processes for these young people span individual, familial, peer, school, and community levels; and (III) desired outcomes encompass both the absence of negative and the presence of positive indicators.

Conclusions

A multisystemic approach to the study of resilience in young people with IBD may not only clarify current gaps in the field, but also allow for additional future considerations to best understand how and for whom outcomes characterized as resilient may occur in this population.

"It's just like putting your socks on": patients' perspectives on inflammatory bowel disease medication adherence

Background

A careful, often life-long, medication regimen is central to therapy for Inflammatory Bowel Disease (IBD) - a chronic gut disorder. Hence, medication adherence (MA) - patients taking medications in line with prescription - is important. Previous research indicates that a third of patients with IBD in southern New Zealand have poor medication adherence (MA).

Objective

This study investigated these patients' experiences to determine factors that influence their MA, for the first time.

Methods

Two focus group discussions (FGDs) were held with IBD patients in Otago, New Zealand. Reflexive thematic analysis from a 'direct realist' viewpoint was used to analyse the data.

Results

Data were analysed in three segments: perceptions, experiences and support. Participants perceived MA as a "duty" that was very important to their wellbeing. The participants' MA was centred around a routine requiring proactivity to maintain. MA was negatively impacted by side effects and regimen factors including (high) pill numbers/dose frequency, and getting refills was framed as challenging; whilst healthcare professionals were presented as major MA facilitators. Lastly, the support structures identified included family, friends and colleagues as well as targeted health system factors e.g. medication subsidies.

Conclusions

Factors spanning those related to the patients, their socioeconomic status, the disease, IBD therapy and the health system were presented as influencing IBD patients' MA in southern NZ. Thus, multifaceted interventions are needed across the health system to overcome the inhibiting and promote the facilitating elements.

Behavioral parenting skills as a novel target for improving medication adherence in young children: Feasibility and acceptability of the CareMeds intervention

In pediatric cancer care, medication non-adherence is a significant driver of avoidable suffering and death. There is a lack of interventions designed for families of young children, where patient medication refusal/avoidance is a common barrier to adherence. We developed the CareMeds intervention which focuses on caregiver skills training to help young children take medicine calmly and without use of restraint techniques. The goal of this preliminary study was to assess the acceptability and feasibility of the CareMeds intervention. Caregivers of pediatric cancer patients (ages 2-10) whose children were on a home-based oral medication regimen were recruited to participate. Feasibility was examined through study enrollment and retention rates as well as reasons for refusal and drop out. Acceptability was evaluated through usability of and engagement with intervention components and an acceptability questionnaire. Feasibility: We recruited N = 9 caregivers to participate in this intervention pilot study and had a 75% enrollment rate. Reasons for declining included scheduling concerns (n = 2) and lack of interest (n = 1). The participant retention rate was 100% with 100% adherence to intervention sessions. Acceptability: Parents rated the sessions and resource materials as acceptable and reported frequent use of skills taught in the intervention. The CareMeds intervention is an acceptable and feasible strategy for caregivers of pediatric cancer patients and warrants future research to examine the efficacy of behavioral parenting skills interventions to improve medication adherence in young children.

Assessing Barriers to use of the Specific Carbohydrate Diet in Pediatric Inflammatory Bowel Disease: A Qualitative Study

Because of the high cost and associated toxicities of pharmacotherapy treatment for inflammatory bowel disease (IBD), there has been growing interest in dietary therapy. The objective of this study is to assess barriers to initiating or maintaining the specific carbohydrate diet (SCD) to inform strategies for improving access and adherence to the diet.

Methods

We conducted semistructured interviews with parents of 10 children with IBD receiving care at a single academic treatment center. Parents were eligible if their child with IBD was either currently on the SCD, previously on the SCD, or opted not to initiate the SCD. Core questions were developed in conjunction with IBD clinical experts. Interviews were transcribed and analyzed using an inductive approach.

Results

Parents of children diagnosed with IBD primarily chose to try the SCD because of concerns about medication safety. Three major barriers to utilizing the SCD emerged: cost, time commitment, and psychosocial impact. Many parents also expressed that following the SCD got easier over time and some parents experienced spillover effects of improved personal health and understanding of nutrition. All parents were strong proponents of the importance of diet in managing IBD and expressed desire for more research into the SCD and other forms of dietary therapy.

Conclusions

These findings provide important insight into factors affecting utilization of the SCD in pediatric IBD. Further research is needed to develop interventions or strategies to diminish these barriers and enable more patients to benefit from the SCD.

Designing Dynamic Interventions to Improve Adherence in Pediatric Long-Term Treatment - The Role of Perceived Value of the Physician by Primary Caregivers

Primary Caregivers are the fulcrum in the physician-caregiver-child triad. Existing literature discusses static multi-component interventions in detail. In long-term treatments, dynamic intervention design is needed as the environment and situations of the families are dynamic. The objectives of this study are (a) to identify the components of the primary caregiver's perception of the physician's value with reference to the effectiveness of consultation and relationships with the former and with the child; (b) to establish the role of this perception in designing dynamic interventions, and (c) to describe the perception's potential influence on adherence. A PRISMA, chronological, and morphological analysis of the literature is carried out about caregivers' adherence in the pediatric long-term treatment context. We define communication and consultation as the functional, whereas relationship as the emotional component of the caregiver's perception of the physician. We propose a theoretical model that incorporates intervention as an integral component of care. Adherence happens as a response to changing situations and hence fluctuates. Hence, a dynamic intervention design to benefit the child should be incorporated into care through the caregiver-physician bridge. Future research should explore how intervention needs change and the driving reasons for understanding the static and dynamic components of interventions.

A qualitative study to explore symptoms and impacts of pediatric and adolescent Crohn's disease from patient and caregiver perspective

BACKGROUND

Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract that affects people across the age spectrum but often starts in childhood or early adulthood. Despite this, almost all published research examining the symptomatic and health-related quality of life (HRQL) experiences of CD has been conducted in an adult population. Studies providing a comprehensive overview of the lived experience of pediatric and adolescent CD are virtually non-existent. The experiences of younger children aged 2-7 years are especially unknown.

RESULTS

A total of 49 participants (31 children and 18 parents) were interviewed. This included 11 dyads (i.e., parents and children from the same family). Analyses were conducted based on reporter-type (patient self-report vs parent observer-report) and age subgroups (ages 2-4 vs 5-7 vs 8-11 vs 12-17). Key symptoms were identified across the age subgroups and reporter types. Abdominal/stomach pain, passing gas/feeling gassy, diarrhea/liquid stools, fatigue/tiredness, bowel urgency, blood in stools, stomach cramping, constipation, and incomplete evacuation were discussed most frequently. The most common HRQL impacts included impact on physical activity, school, social life, and mood (i.e., feeling sad/low), and were mostly consistent between reporter type and across age spectrum. Concept agreement between parents and children in the dyad analysis was > 60% for most symptoms and impacts.

CONCLUSIONS

Qualitative interviews revealed the substantial symptom and HRQL burden of pediatric CD from the child and parent perspectives and that disease experiences were largely consistent across the age range and based on both reporter perspectives. This is an important first step towards implementing a robust measurement strategy for the assessment of symptoms and HRQL impacts in pediatric CD.

Factors contributing to fidelity in a pilot trial of individualized resistant starches for pediatric inflammatory bowel disease: a fidelity study protocol

Background

The consumption of resistant starches is a promising adjuvant therapy for patients with inflammatory bowel disease. Rigorous evaluation of resistant starches in this setting depends on the intervention being delivered, received, and enacted as intended, that is, with fidelity. As part of a planned pilot trial, participants will be randomized to ingest resistant starches or a placebo. They will also be asked to collect stool samples and keep symptom and dose diaries to inform trial outcomes.

We aim to identify potential factors impacting fidelity to the receipt and enactment of trial intervention and data collection activities from the perspective of patients and caregivers in the trial. Identifying fidelity barriers and enablers at the pilot trial phase of a clinical intervention may help to determine optimization processes when expanding to multiple sites in future trials.

Methods

We will conduct 15-30 semi-structured interviews with pilot trial participants (aged 8-17) and their caregivers. Trial participants will be approached for interviews approximately 6 months after the start of their trial participation. Personal projects analysis, a tool for understanding how individuals manage competing demands in their daily lives, will guide an in-depth exploration of how trial participants engage in activities related to intervention and data collection fidelity (ingesting resistant starches or placebo, collecting stool samples, keeping a symptom and dose diary) amidst the complexities of daily living.

Discussion

The present study will seek to explore and demonstrate how theory-informed fidelity assessments can be conducted alongside pilot trials to inform future multisite trials. Study results will clarify what factors may affect fidelity to trial intervention and data collection activities. Results may suggest what to modify to optimize the design and conduct, and ensure the integrity, of future multisite trials. Conducting process evaluations alongside clinical trials has the potential to improve our understanding of trial participant experiences. Results will provide a better understanding of how trial participants manage to engage in necessary trial activities along with other priorities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00815-1.

Medication adherence: a qualitative exploration of the experiences of adolescents with systemic lupus erythematosus

INTRODUCTION/OBJECTIVE

There are increasing numbers of children diagnosed with systemic lupus erythematosus (SLE). Given the chronicity of the disease, individuals are confronted with cocktails of medications for an extended period. The present study explores experiences in medication adherence among adolescents with SLE in an acute care hospital.

METHOD

A descriptive qualitative design was employed. Fourteen adolescents with SLE were purposively selected. Face-to-face audio-recorded semi-structured interviews were conducted. Field notes and reflexive journals were maintained, and frequent debriefing sessions were performed to ensure the study's methodological rigour. Interviews were transcribed verbatim and thematic analyses were used. Constant comparative analysis was used to identify similarities and differences among the participants.

RESULTS

Four themes emerged from interviews: (1) making sense of the treatment; (2) contending with side effects of medications; (3) maintaining networks of support; and (4) creating a new normal. The participants were motivated to adhere to medications when they developed awareness, received social support from family and friends and created routines for new normal when confronted with their diseases. However, some attributed a lack of parental support, poor doctor-patient relationships and the large numbers of medications as deterrence to medication adherence.

CONCLUSIONS

This study highlights various medication-taking motivators and deterrents. Interdependent relationships between motivators and deterrents determine medication-taking behaviours. Findings from this multi-ethnic group of individuals of various ages and religious faith across the disease trajectory provide a deep insight into adolescents' experiences of medication adherence. This can contribute to the development of unique interventions for such individuals. Key points • Adolescents with systemic lupus erythematosus struggle with conforming to cocktails of medications. • A variety of factors either facilitate or impede their decisions to adhere to medication regimes. • Results suggest that tackling medication adherence among adolescents requires a multi-pronged approach from individual, familial and medical perspectives.

The Development of Health Self-Management Among Adolescents With Chronic Conditions: An Application of Self-Determination Theory

PURPOSE

The purpose of the study was to better understand the progressive development of health self-management among adolescents and emerging adults (AEAs) with chronic medical conditions in order to identify opportunities to prepare AEA for transition to adult-based care.

METHODS

Twenty-three AEA aged 17-20 years with renal, inflammatory bowel, or rheumatologic diseases, and their parents, completed individual semistructured interviews describing each AEA's health self-management. Self-Determination Theory was used to frame interview questions, including the constructs of competence, autonomy, and autonomy support. Transcripts were analyzed using directed content analysis.

RESULTS

Four themes emerged: Development of Competence in Self-Management; Autonomy: Motivations to Self-Manage; Ways Important Others Support or Hinder Independence; and Normal Adolescent Development. AEA's competency and autonomy increased as they progressed from lack of knowledge about self-management to having knowledge without doing tasks, and, ultimately, to independent completion of tasks. Motivations to self-manage included avoiding sickness/weakness and wanting to engage in activities. Parents and providers supported AEA's autonomy through teaching and transferring responsibility. Parental fear/lack of trust in AEA's ability to self-manage hindered development of AEA's autonomy, producing anxiety. Normal adolescent development impacted timing of self-management task mastery.

CONCLUSIONS

As AEA gain competence in increasingly complex self-management tasks, they assume greater responsibility for managing their health. Competence and autonomy are facilitated by a feedback loop: AEA successful self-management increased parent trust, enabling the parent to transfer responsibility for more complex tasks. Conversely, parents' fear of the AEA doing wrong hinders transfer of responsibility, limiting competence and autonomy. Health-care providers play an important role in fostering autonomy.

Evaluating a Standardized Transition of Care Process for Pediatric Inflammatory Bowel Disease Patients

To reduce lapses in care for pediatric inflammatory bowel disease (IBD) patients approaching adulthood, a health maintenance transition visit (HMV) was developed to supplement standard medical care (SMV). Our aim was to assess the effect of the HMV on transition readiness. A retrospective chart review was conducted at a single center with demographics and clinical data from HMV and SMV visits. Effectiveness of the HMV was assessed by the patient health questionanaire-9 (PHQ-9) and transition readiness assessment questionnaire (TRAQ) scores. A total of 140 patients, 80% Caucasian and 59% male completed an HMV. The mean age was 18 ± 2 years old, and 93% of patients reported inactive or mild disease. Patients who completed at least 1 prior HMV scored significantly higher on the TRAQ when transferring to adult care compared to patients transferred at their first HMV visit (92 vs. 83, p < 0.05). Of patients with no prior depression diagnosis, 36% had a positive screen for depression. A significant relationship was identified between disease status and PHQ-9 (p < 0.05). This study demonstrated a structured HMV increased transition readiness and quantified the significant under-diagnosis of depression in this population, emphasizing the importance of screening. These results indicate depression may affect patients' transition preparedness.

Parent and Family Functioning in Pediatric Inflammatory Bowel Disease

Although the impact of pediatric inflammatory bowel disease (IBD) extends beyond the patient to their parents and families, the focus of previous literature has largely been on investigating the patient’s medical and psychosocial functioning, with less consideration of the family system. Having a comprehensive understanding of parent and family functioning within the context of pediatric IBD is important given the role parents and family members have in the successful management of the disease and caring of the child. The current review paper aggregates the empirical research regarding parent and family functioning, including comparisons to normative samples, other illness groups, and how functioning relates to child psychosocial and health outcomes. Extant literature on parents and families in pediatric IBD has largely focused on the variables of parenting stress, parent psychosocial functioning, parent quality of life, and family functioning. Summary findings elucidate the complex relationships between parents, families, and children affected by IBD and highlight the importance of assessing parent and family functioning within pediatric IBD. The current review also offers implications for clinical practice, notes the limitations of the present literature, and provides recommendations for future research.

Adherence to Azathioprine/6-Mercaptopurine in Children and Adolescents with Inflammatory Bowel Diseases: A Multimethod Study

BACKGROUND

Measurement of the degree of adherence is a key element for the evaluation of treatment efficacy and safety; thus, adherence plays an important role in clinical research and practice. The aim of this study was to investigate medication adherence in children with inflammatory bowel disease (IBD) utilizing a multimethod assessment approach. A further aim was to examine factors that can influence adherence within this population.

METHODS

Medication adherence in 47 children (age range 3 to 17 years) with IBD in three centers in Northern Ireland and Jordan was assessed via subjective (parent and child versions of the Medication Adherence Report Scale (MARS) specific questionnaire) and objective methods, that is, high-performance liquid chromatography (HPLC) determination of the 6-mercaptopurine (6-MP) and azathioprine (AZA) metabolites in packed red blood cell samples taken during a clinic visit. Beliefs about prescribed medicines were also assessed in parents/guardians using the Beliefs about Medicines Questionnaire (BMQ).

RESULTS

An overall nonadherence to AZA/6-MP therapy in children with IBD was found to be 36.17% (17 out of 47 patients were classified as nonadherent using at least one of the assessment methods). A total of 41 patients (91.1%) were classified as adherent to AZA or 6-MP using the blood sampling, while adherence rates using the MARS questionnaire completed by children and parents/guardians were 60.6% and 72.7%, respectively. The latter provides a more longitudinal measure of adherence. Child self-reported nonadherence rates were significantly higher than parent/guardian reported rates (p=0.013). Binary logistic regression analysis identified age to be independently predictive of adherence, with adolescents (children aged ≥ 13 years old) more likely to be classified as nonadherent. Regarding the BMQ, when parental/guardian necessity beliefs outweighed concerns, that is, higher scores in the necessity-concern differential (NCD), adolescents were more likely to be classified as adherent.

CONCLUSION

Results provide evidence for ongoing adherence challenges in the paediatric population with IBD. It is recommended that parents/guardians (particularly of older children) and older children themselves, should receive enhanced counselling and education about their prescribed medicines.

Response pattern analysis of IBD-KID: A knowledge assessment tool for children with inflammatory bowel disease

AIM

Paediatric inflammatory bowel disease (IBD) is a chronic relapsing condition requiring adherence to complex treatment regimens to achieve best outcomes. Adherence is frequently low in this population but can be improved by increasing disease- and treatment-related knowledge. The IBD-knowledge inventory device (IBD-KID) is a knowledge assessment tool specifically developed and validated for children with IBD. To analyse IBD-KID participant response patterns in order to review the strength of the tool.

METHODS

A cohort of children with IBD completed IBD-KID, and their responses were used to assess the tool's validity and feasibility. Item response analysis assessed the item difficulty and the ability of items to discriminate between high/low scorers. The analysis considered item structure, readability and the effectiveness of multiple choice items.

RESULTS

A total of 105 completed IBD-KID assessments showed that 12 items (52%) had an acceptable difficulty level, and 17 (74%) were effective at discriminating between high/low scorers. Nine (61%) had good readability, but comprehension levels ranged from 5 to 18 years. Seven (30%) had elevated 'don't know' responses, highlighting the need for content and construction review. Of the 10 multiple choice items, 9 were complex and not functioning efficiently. Internal consistency was acceptable but could be improved by removing two items.

CONCLUSIONS

The response analysis metrics were reviewed by an expert panel and provided a framework for IBD-KID improvements with the aim of increasing discrimination and reducing difficulty without adversely affecting reliability. The proposed revisions will address components that may have caused children to answer incorrectly due to confusion rather than lack of knowledge.

Perceived Need for Treatment and Engagement in Mental Health Services Among Community-Referred Racial/Ethnic Minority Adolescents

This study examines clinical and family predictors of perceived need for treatment and engagement in mental health treatment services among community-referred racial/ethnic minority adolescents and their primary caregivers. Findings indicated that the majority of families perceived a need for treatment, but that perceived need was not associated with treatment engagement. Family factors (i.e., low cohesion and high conflict within the family) predicted perceived need for treatment among adolescents, whereas clinical factors (i.e., adolescent internalizing and externalizing symptomatology) predicted caregiver perceived need for adolescent treatment. Neither clinical nor family factors predicted treatment engagement.

Assessing the Transition Intervention Needs of Young Adults With Inflammatory Bowel Diseases

OBJECTIVES

The transition of inflammatory bowel disease (IBD) patients from pediatric to adult care can be challenging. Developing an effective transition intervention requires assessing the current transition experience for potential improvements, determining preferred content and format, and assessing patients' transition skills.

METHODS

This mixed-methods study of 20 transitioned IBD patients (ages 17-20 years) used semistructured interviews and validated assessments of self-management/self-advocacy and IBD knowledge. Interviews were analyzed thematically. Assessment scores were compared with published reference data by estimating proportion or mean differences and 95% confidence intervals (CIs).

RESULTS

The concept of a transition intervention was well-received by participants. Preferred content centered on medications, disease and what to expect. Preferred ways to acquire knowledge were one-on-one instruction, handouts, and websites. Identified themes were "individualized and multifaceted," "teach about transition," and "support the shift in responsibility." Among participants, 95% did not achieve 90% mastery of transition skills (0.6% higher [95% CI -10.7% to 9.5%] than the reference estimate) and the mean knowledge score was 15.15 (3.86 [95% CI 2.27 to 5.45] points higher than the reference estimate).

CONCLUSIONS

We have identified preferred intervention formats and content as well as skill areas to target for improvement. As a result of this work, we will design a website intervention pertaining to identified themes.

Attention-Deficit/Hyperactivity Disorder Medication Use in Adolescents: The Patient's Perspective

PURPOSE

The purpose of the study was to gain more insight into the attitudes of adolescents using medication for attention-deficit/hyperactivity disorder (ADHD).

METHODS

A cross-sectional study among adolescents (aged 12-18 years) who filled at least two prescriptions for ADHD medication in the preceding year was conducted. Adolescents were invited to fill in an online questionnaire containing questions on sociodemographics, health status, illness perceptions, medication adherence, and medication beliefs.

RESULTS

We invited 1,200 adolescents of whom 181 adolescents (122 males, mean age 14.2 ± 1.7 years) completed the online questionnaire. They mostly used methylphenidate (n = 167; 92%) as a pharmacological treatment for ADHD. Half of the study population (n = 93; 51%) experienced side effects, such as decreased appetite and sleep problems. Most participants (n = 150; 83%) had an indifferent attitude (perceived low necessity and low concerns) toward their ADHD medication. More than half of the study population (n = 111; 61%) reported to be nonadherent based on the Medication Adherence Report Scale. The highest score of the Brief Illness Perception Questionnaire was on "treatment control," suggesting that adolescents do think their medication is effective, despite their indifferent drug attitude.

CONCLUSIONS

Most adolescents using ADHD medication had an indifferent attitude toward their medication and reported low adherence rates. These findings should be taken into account when treating adolescents with ADHD; regular counseling and monitoring of the pharmacological treatment might be useful to optimize treatment.

An assessment of the experiences and needs of adolescents with chronic conditions in transitional care: a qualitative study to develop a patient education programme

The transition of adolescents with chronic conditions is a challenging task. This study aimed to explore the experiences and needs of adolescents with chronic conditions in the transition period and to apply these findings to the design of a generic patient education programme. Data were collected from a sample of 29 adolescents with chronic conditions from Northern Germany and Switzerland including a broad range of views due to variation in disease management and organisation of care both in paediatric and adult populations. Participants were interviewed in group (n = 18) or individual (n = 11) interviews between September 2011 and February 2012, and the data were analysed using qualitative content analysis. The findings revealed that the interviewees expressed high levels of competency in the management of their chronic conditions but identified gaps in healthcare and unmet needs during transition. In particular, they believed that they would benefit from opportunities to exchange ideas and more specific information with peers about vocational and medical issues concerning adolescent health. Identified themes reflecting adolescent needs were used to develop the transition workshop including modules regarding the following: transfer to adult medicine, their new role as a patient, orientation within the healthcare system, vocational issues, detachment from parents, social support, contraception, substance abuse, family planning, stress-management, activation of resources and developing personal goals. The workshop's content was largely generic and included some condition-specific components. The workshop was designed as a compact 2-day patient education programme in a group setting for adolescents prior to their transfer to adult care. The guiding principle was the idea of empowerment by supporting the adolescents through various interactive methods to develop adequate knowledge, skills, understanding and motivation regarding their chronic conditions. We conclude that patient education programmes promoting adolescent self-management and empowerment increase the preparedness for transition.

Adherence to Oral Maintenance Treatment in Adolescents With Inflammatory Bowel Disease

OBJECTIVES

The aim of this study was to systematically review the rates of nonadherence to oral maintenance treatment in adolescents with inflammatory bowel disease (IBD), and to describe perceived barriers to adherence and psychosocial factors involved.

METHODS

The article considered studies published in MEDLINE, Embase, and PsycINFO up to March 2015. Studies that had collected data on adherence to thiopurines or aminosalicylates in a cohort of adolescents with IBD. Case reports and case series were excluded.

RESULTS

A total of 25 studies were included. Lack of uniformity of outcome measures made pooling of data impossible. Rates of medication nonadherence ranged from 2% to 93%. The most frequently reported barriers were "just forgot," "wasn't home," and "interferes with activity." Family dysfunction, peer victimization, poor health-related quality of life, poor child-coping strategies, anxiety, and depressive symptoms were associated with medication nonadherence.

CONCLUSIONS

Nonadherence to oral maintenance therapy in adolescents with IBD is a significant health care problem and can lead to unnecessary escalation in therapy. Difficulties in family and social interactions, and psychosocial dysfunction can jeopardize IBD treatment outcome and should receive attention early in the course of the disease.

Pediatric glaucoma medical therapy: who more accurately reports medication adherence, the caregiver or the child?

As they grow older, most children with glaucoma must eventually face the transition to self-administering medications. We previously reported factors associated with better or worse medication adherence in children with glaucoma, using an objective, electronic monitor. Utilizing the same data set, the purpose of the current study was to determine whose report (the caregiver’s or the child’s) corresponded better with electronically monitored adherence. Of the 46 participants (22 girls), the mean age of children primarily responsible, and caregiver primarily responsible for medication administration was 15±2 and 10±2 years, respectively. For the children whose caregiver regularly administered the eyedrops, the caregiver’s assessment of drop adherence was associated with measured adherence (P=0.012), but the child’s was not (P=0.476). For the children who self-administered eyedrops, neither the child’s (P=0.218) nor the caregiver’s (P=0.395) assessment was associated with measured percent adherence. This study highlights potential errors when relying on self-reporting of compliance in patients and caregivers with pediatric glaucoma, particularly when the child is responsible for administering their own eyedrops. Frank discussions about the importance of medication adherence and how to improve compliance may help both the child and caregiver better communicate with the treating provider.

Transition experience of young adults with inflammatory bowel diseases (IBD): a mixed methods study

BACKGROUND

Outcomes following transition can be poor; many young adults are ill prepared to take responsibility for their health care, older adolescents report incomplete understanding of medications, and parents remain largely responsible for their care. Good patient-provider relationships are associated with better adherence; however, the role of the relationship between post-transition patients and their providers has not been explored. The current study aimed to understand transition of young adults with inflammatory bowel diseases (IBD), the impact of the paediatric patient-provider relationship and what determines the adult patient-provider relationship.

METHODS

This study examined the experience of young adults with Crohn's disease or ulcerative colitis (aged 18-30) after transition. Twenty-nine patients completed a 31-item online survey of their transition experience from paediatric to adult care. Responses were coded quantitatively and qualitatively, and qualitative responses were analysed by two independent raters.

RESULTS

Positive themes regarding adult providers included independence, autonomy and trust, while negative themes included initial discomfort and confusing logistics. Five of six patients who reported 'terrifying' first visit experiences with their adult providers reported overall positive relationships. The earlier the diagnosis age, the less involved in medical decisions they were as an adult (r = 0.41, P = .03). Those who had a more positive experience with their paediatric providers were more likely to bring up confusion with their adult providers (r = .45, P = .04), and those who had a more positive experience with their adult providers were more likely to endorse collaborative medical decision-making (r = .57, P < .001).

CONCLUSIONS

Patients diagnosed with IBD at a young age may need extra education and self-management strategies, as they were less likely to exhibit behaviours indicative of a successful transition to adult care. Additionally, transition programme development may benefit from the post-transition perspective across chronic illness populations.

"I just forget to take it": asthma self-management needs and preferences in adolescents

BACKGROUND

Medication adherence rates often decline as children become teenagers. Effective adherence-enhancing interventions for adolescents are lacking. The objective of this study was to assess adolescent asthmatics needs and preferences regarding medication counseling and support, with focus on new media.

METHODS

Three focus groups including 21 asthmatic adolescents recruited from both primary and secondary care were held to explore needs and preferences regarding asthma-self management. Questions concerned adherence behavior and needs and preferences in adherence support with focus on new media (mobile technology, social media, health games).

RESULTS

Forgetting was mentioned as major reason for not using medication as prescribed. Adolescents also mentioned lack of perceived need or beneficial effects. Parents mainly play a role in reminding to take medication and collecting refills. The suggested strategies to support self-management included smartphone applications with a reminder function and easy access to online information. Participants were positive about sharing of experiences with other teenagers.

CONCLUSION

Forgetfulness is a major reason for non-adherence in adolescents. Furthermore, our results suggest use of peer support may be helpful in promoting good medication use. Future interventions should be aimed at providing practical reminders and should be modifiable to individual preferences.

Adolescents' inhaled corticosteroid adherence: the importance of treatment perceptions and medication knowledge

BACKGROUND

Studies measuring inhaled corticosteroid (ICS) adherence frequently report adherence rates below 50%. Although asthma is common in adolescents, few studies have explored determinants of ICS adherence in adolescents. The objective of this study was to examine adherence and related factors in adolescent ICS users.

METHODS

Adolescent ICS users, aged 12-18 years, were randomly recruited from a sample of 94 community pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research to complete an online questionnaire. The survey contained questions on asthma control, self-reported adherence, medication beliefs and medication knowledge. Data were collected between April and August 2013.

RESULTS

Complete questionnaire data were received from 182 adolescents of which 40% reported to be adherent. Approximately 40% of the participants perceived strong needs, whilst only 10% was highly concerned about adverse effects regarding their ICS use. Good adherence was significantly associated with asthma control (OR: 2.1, 95% CI: 1.1-4.1). Necessity beliefs and sufficient medication knowledge were associated with better adherence (p < 0.05).

CONCLUSION

Our results suggest that by improving knowledge about asthma treatments and stimulating positive perceptions towards medicines, especially regarding the necessity of medication use, better adherence rates might be achieved.

Coping with college and inflammatory bowel disease: implications for clinical guidance and support

BACKGROUND

Studies have shown that young adults with chronic diseases, including inflammatory bowel disease (IBD), experience greater difficulty during the transition to college, reaching lower levels of educational attainment and reporting greater levels of perceived stress than their otherwise-healthy peers. We performed a qualitative study to better understand how underlying illness shapes the college experience for patients with IBD and how the college experience, in turn, impacts disease management.

METHODS

Fifteen college students with IBD were recruited from the Boston Children's Hospital Center for IBD. We conducted an approximately 1 hour semistructured qualitative interview with each participant, and the interviews were thematically analyzed after an iterative and inductive process.

RESULTS

Four primary themes were identified: (1) The transition experience of college students with IBD is shaped by their health status, perceived readiness, and preparedness, (2) Elements of the college environment pose specific challenges to young adults with IBD that require adaptive strategies, (3) College students with IBD integrate their underlying illness with their individual and social identity, and (4) College students navigate health management by conceptualizing themselves, their families, and providers as serving particular roles.

CONCLUSIONS

For young adults with IBD, college is a proving ground for demonstrating self-care and disease management practices. Future initiatives aimed at this population should recognize the evolving roles of patients, parents, and providers in disease management. Increased attention should also be paid to the promotion of patient's self-management and the unique challenges of the structural and psychosocial college environment.

Medication adherence in adolescents in current practice: community pharmacy staff's opinions

OBJECTIVE

To explore pharmacy staff's perspectives regarding medication use behaviour in adolescent patients.

METHODS

Structured face-to-face interviews were conducted with 170 community pharmacy staff members.

KEY FINDINGS

Medication-related problems in adolescents had been experienced by 80 respondents; non-adherence was frequently mentioned (n = 73). An important reason for medication-related problems in adolescents not being recognised was that prescriptions are often collected by the parents (with or without the teenager). Solutions suggested by the interviewees to improve adolescents' medication use behaviour included (improving) counselling with emphasis on necessity/benefits of medication (n = 130) and more direct contact with adolescents instead of parent(s) (n = 77). Use of digital media for educational purposes or reminder services was suggested to support medication use (n = 67).

CONCLUSIONS

Almost half of pharmacy staff experienced problems related to medication use in adolescents. Pharmacy staff see a primary role for counselling on the benefits of therapy but foresee difficulties in obtaining direct contact with adolescents. Use of new media could be useful.

Self-reported barriers to medication adherence among chronically ill adolescents: a systematic review

PURPOSE

To investigate self-reported barriers to medication adherence among chronically ill adolescents, and to investigate whether barriers are unique to specific chronic diseases or more generic across conditions.

METHODS

A systematic search of Web of Science, PubMed, Embase, PsycINFO, and CINAHL from January 2000 to May 2012 was conducted. Articles were included if they examined barriers to medication intake among chronically ill adolescents aged 13-19 years. Articles were excluded if adolescent's views on barriers to adherence were not separated from younger children's or caregiver's views. Data was analyzed using a thematic synthesis approach.

RESULTS

Of 3,655 records 28 articles with both quantitative, qualitative, and q-methodology study designs were included in the review. The synthesis led to the following key themes: Relations, adolescent development, health and illness, forgetfulness, organization, medicine complexity, and financial costs. Most reported barriers to adherence were not unique to specific diseases.

CONCLUSION

Some barriers seem to be specific to adolescence; for example, relations to parents and peers and adolescent development. Knowledge and assessment of barriers to medication adherence is important for both policy-makers and clinicians in planning interventions and communicating with adolescents about their treatment.

Factors associated with thiopurine non-adherence in patients with inflammatory bowel disease

BACKGROUND

Medication non-adherence seems to be a particular problem in younger patients with inflammatory bowel disease (IBD) and has a negative impact on disease outcome.

AIMS

To assess whether non-adherence, defined using thiopurine metabolite levels, is more common in young adults attending a transition clinic than adults with IBD and whether psychological co-morbidity is a contributing factor. We also determined the usefulness of the Modified Morisky 8-item Adherence Scale (MMAS-8) to detect non-adherence.

METHODS

Seventy young adults [51% (36) male] and 74 [62% (46) male] adults were included. Psychological co-morbidity was assessed using the Hospital Anxiety Depression Scale (HADS) and self-reported adherence using the MMAS-8.

RESULTS

Twelve percent (18/144) of the patients were non-adherent. Multivariate analysis [OR, (95% CI), P value] confirmed that being young adult [6.1 (1.7-22.5), 0.001], of lower socio-economic status [1.1 (1.0-1.1), <0.01] and reporting higher HADS-D scores [1.2 (1.0-1.4), 0.01] were associated with non-adherence. Receiver operator curve analysis of MMAS-8 scores gave an area under the curve (95% CI) of 0.85 (0.77-0.92), (P < 0.0001): using a cut-off of <6, the MMAS-8 score has a sensitivity of 94% and a specificity of 64% to predict thiopurine non-adherence. Non-adherence was associated with escalation in therapy, hospital admission and surgeries in the subsequent 6 months of follow up.

CONCLUSIONS

Non-adherence to thiopurines is more common in young adults with inflammatory bowel disease, and is associated with lower socio-economic status and depression. The high negative predictive value of MMAS-8 scores <6 suggests that it could be a useful screen for thiopurine non-adherence.

Parenting stress in pediatric IBD: relations with child psychopathology, family functioning, and disease severity

OBJECTIVE

Parenting stress in pediatric inflammatory bowel disease (IBD) has been under-examined. Data validating use of the Pediatric Inventory for Parents (PIP), a measure of parenting stress associated with caring for a chronically ill child, in chronic diseases with intermittent, unpredictable disease courses, such as IBD, are needed. This study presents validity data in support of the PIP in pediatric IBD and examines relations between parenting stress and important psychosocial and medical outcomes.

METHODS

Adolescents (N = 130) with IBD and their caregivers across 3 sites completed measures of parenting stress, family functioning, and emotional/behavioral functioning. Disease severity was also assessed for each participant.

RESULTS

The PIP demonstrates excellent internal consistency. Parenting stress was significantly higher among those with unhealthy general family functioning and those with children with borderline or clinically elevated internalizing symptoms. Caregiving stress was greater among parents of youth with more active Crohn's disease.

CONCLUSION

Results supported the reliability and validity of the PIP for assessing caregiving stress in pediatric IBD. Routine assessment of parenting stress is recommended, particularly among parents reporting unhealthy family functioning and parents of youth with borderline or clinically elevated internalizing symptoms and more active disease.

A systematic review of self-management interventions for children and youth with physical disabilities

PURPOSE

Evidence shows that effective self-management behaviors have the potential to improve health outcomes, quality of life, self-efficacy and reduce morbidity, emergency visits and costs of care. A better understanding of self-management interventions (i.e. programs that help with managing symptoms, treatment, physical and psychological consequences) is needed to achieve a positive impact on health because most children with a disability now live well into adulthood.

METHOD

A systematic review of self-management interventions for school age youth with physical disabilities was undertaken to assess their effectiveness. Comprehensive electronic searches using international web-based reference libraries were conducted for peer-reviewed and gray literature published between 1980 and January 2012. Eligible studies examined the effectiveness of self-management interventions for children and youth between 6 and 18 years of age with congenital or acquired physical disabilities. Studies needed to include a comparison group (e.g. single group pre/post-test design) and at least one quantifiable health-related outcome.

RESULTS

Of the 2184 studies identified, six met the inclusion criteria; two involved youth with spina bifida and four with juvenile arthritis. The majority of the interventions ran several sessions for at least 3 months by a trained interventionist or clinician, had one-to-one sessions and meetings, homework activities and parental involvement. Although outcomes varied between the studies, all of the interventions reported at least one significant improvement in either overall self-management skills or a specific health behavior.

CONCLUSIONS

While self-management interventions have the potential to improve health behaviors, there were relatively few rigorously designed studies identified. More studies are needed to document the outcomes of self-management interventions, especially their most effective characteristics for children and youth with physical disabilities. Implications for Rehabilitation There is some evidence to suggest that self-management interventions for children and youth with spina bifida and arthritis can improve self-management behaviors and health outcomes. Parents' involvement should be considered in encouraging self-management behaviors at different stages of their child's development. Much work is needed to explore the longer term implications of self-management interventions for youth with physical disabilities as well as the impact on health care utilization.

Evaluation of a group-based behavioral intervention to promote adherence in adolescents with inflammatory bowel disease

OBJECTIVE

To pilot test the feasibility and acceptability of a family-based group behavioral intervention and to improve medication adherence in adolescents diagnosed with inflammatory bowel disease.

METHODS

Participants were 40 adolescents aged 11-18 years diagnosed with inflammatory bowel disease and their primary caregivers, who were randomized to either a four-session Family-Based Group Behavioral Treatment or Usual Care over a 6-week period. Adherence was measured using a multi-method, multi-informant assessment involving caregiver-report and patient-report, pill count data, and electronic monitoring.

RESULTS

Adherence rates ranged from 66 to 89% for 6-mercaptopurine/azathioprine and 51 to 93% for mesalamine across assessment methods. The intervention was feasible, as evidenced by the 99% treatment session attendance rate, and acceptable based on patient and caregiver report. Repeated measures analysis of variance tests revealed nonsignificant differences between the conditions from baseline to post-treatment assessments for pill count, electronic monitor, and primary caregiver-reported adherence (P's>0.05). There was a statistically significant improvement in patient-reported mesalamine adherence represented by a significant main effect for Condition (F=22.24, P<0.01; δ=0.79) and Condition×Time interaction (F=13.32, P<0.05; δ=0.69).

CONCLUSION

Findings suggest potential for use of behavioral intervention to improve medication adherence in this population. This intervention may be more effective with more complex regimens (e.g. multiple doses per day) such as those prescribed with mesalamine. Further research is needed to examine this type of intervention in more diverse samples with more active disease. Use of alternative adherence measurement approaches, including electronic pill boxes and/or real-time self-report (e.g. by text messaging, electronic diaries, etc.) is also recommended.