The impact of elexacaftor/tezacaftor/ivacaftor on cystic fibrosis health-related quality of life and decision-making about daily treatment regimens: a mixed methods exploratory study

Background

Elexacaftor/tezacaftor/ivacaftor (ETI) has reduced many symptoms of cystic fibrosis (CF).

Objectives

We sought to identify the impact of ETI on both symptoms and treatment decisions among adults with CF.

Design

Participants were enrolled in a cross-sectional study. Surveys were sent via a RedCap link. Semistructured interviews were administered remotely via Microsoft Teams. Interviews were audio recorded and professionally transcribed.

Methods

We assessed Cystic Fibrosis Questionnaire-Revised (CFQ-R) subscales for physical, respiratory, emotion, and treatment, and analyzed semistructured interviews covering CF treatment regimens and daily living. Quantitative and qualitative results were analyzed separately and via a mixed-methods convergence coding matrix.

Results

Twenty-four adults with CF taking ETI were included. CFQ-R subscale scores (mean scores/standard deviation) were physical (82.1/22.8), respiratory (83.7/11.2), emotion (65.3/14.2), and treatment (57.5/20.1). Three themes about decision-making for non-ETI-treatments emerged: (1) How I'm feeling, (2) Not noticing a difference, and (3) Uncertainty about long-term impact of modifying treatment regimens, and we found participants weighed each of these factors in their treatment decisions. Key findings from mixed-methods analysis show that among individuals experiencing higher CFQ-R scores for physical and respiratory compared to emotion and treatment, there were statements indicating that while those participants were experiencing better physical health, many continued their burdensome treatment regimens.

Conclusion

With little long-term data on the impact of reducing non-ETI treatments, participants weighed how they were feeling, treatment efficacy beliefs, and risk tolerance when making treatment decisions.

Self-care deficits reported by school children with cystic fibrosis

BACKGROUND

Self-care refers to the ability that an individual has or develops to regulate the functioning of the body. Health status and age are factors associated with dependency on, and the need for, someone else to take over self-care. In the present case, there was a self-care deficit. Cystic fibrosis is a chronic disease that occurs in one in 10,000 live births in Brazil, and the affected population in the country is predominantly pediatric (approximately 73%). Support from nursing teams is necessary to improve patients' skills until they can take full responsibility for their self-care.

PURPOSE

This study aimed to identify self-care deficits based on reports from schoolchildren with cystic fibrosis.

DESIGN AND METHOD

A qualitative study was conducted with eight Brazilian schoolchildren with cystic fibrosis, using an art-based technique during interviews. Minayo's thematic analysis was used for data analysis and interpretation.

RESULTS

These results emerged from Orem's theory of self-care deficits and needs. A main theme labeled as universal self-care requisites was identified, and three subthemes were derived-maintenance of an adequate air supply; maintenance of a balance between activity and rest; and avoiding risks to life, bodily functions, and well-being.

CONCLUSION

Schoolchildren living with cystic fibrosis have a negative attitude toward their disease, which makes it difficult for them to acquire the ability to care for themselves with greater autonomy. This leads to deficits in the self-care delivered by providers.

IMPLICATIONS TO PRACTICE

It is necessary to recognize the deficits in self-care and the extent to which children living with cystic fibrosis depend on self-care providers. Families must be aware of these self-care deficits to develop holistic self-care abilities.

Considering Social Identity Threat Alongside the Health Belief Model to Examine Mask-Wearing Intentions of Black, Latinx, and Asian Individuals in the U.S. During COVID-19

During the COVID-19 pandemic, U.S. public health officials have recommended various safety protocols to "stop the spread", and atop the list is wearing a mask. Individuals from particular racial groups have also contended with a surge of racial profiling and race-based discrimination that has positioned mask-wearing as a risky yet health-promoting behavior. Using the health belief model (HBM), this study considers how racism and health intersect by examining the emotions, behavioral intentions, and health outcomes of mask-wearing among Black, Latinx, and Asian individuals. Cross-sectional survey data from 521 participants from across the United States were collected and analyzed using quantitative analyses. Results did not indicate significant differences in mask-wearing intentions between racial groups as predicted by the health belief model constructs; however, group differences in experiences of racism did shape perceptions of and behaviors related to mask-wearing. Mask-wearing was also related to more positive emotional experiences, and social cues to action predicted intentions to wear a mask. Implications for encouraging health-promoting behaviors across diverse populations during public health crises are discussed.

Mothers' Decision Making Concerning Safe Sleep for Preterm Infants: What Are the Influencing Factors?

BACKGROUND

Parental decisions regarding infant sleep practices vary widely, resulting in a lack of adherence to the American Academy of Pediatrics safe sleep recommendations (SSR) and consequently an increased risk of sudden infant death syndrome (SIDS). Preterm infants are among those at a highest risk for SIDS, yet few studies focus on parental decision-making surrounding sleep practices for preterm infants.

PURPOSE

The purpose of this study was to identify factors influencing decisions concerning infant sleep practices of mothers of preterm infants.

METHODS

This study used a mixed-methods design. Recruitment was through social media messaging by 2 parent support organizations. An online survey was used to assess factors influencing mothers' decisions regarding sleep practices for preterm infants.

FINDINGS/RESULTS

Survey participants (n = 98) were from across the United States. Mothers of preterm infants (mean gestational age at birth = 29.42 weeks) most often reported positioning infants on their back to sleep (92.3%) and a low (15.4%) use of a pacifier at sleep time. Three themes emerged for the decisions made: adherence to SSR; nonadherence to SSR; and infant-guided decisions. Regardless of the decision, mothers indicated that anxiety over the infant's well-being resulted in a need for sleep practices that facilitated close monitoring of the infant.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The findings of this study indicate the need for understanding the underlying anxiety preventing mothers from adhering to SSR despite knowing them, along with tailoring infant sleep messaging and education to improve safety of sleep practices for preterm infants. Research is needed to examine decision making in more diverse populations.

Factors impacting adolescent and young adult cancer patients' decision to pursue genetic counseling and testing

PURPOSE

Adolescent and young adult (AYA) cancer patients face challenges when navigating cancer treatment and survivorship. Many are at risk for cancer predisposition syndromes; however, factors influencing pursuit of genetic counseling and testing have not been reported. We describe AYA cancer patients' decision-making process, including motivational factors and barriers, as it relates to utilization of genetic services.

METHODS

Thirty AYAs diagnosed with cancer previously referred for cancer predisposition genetic counseling completed semi-structured interviews via audio-only Zoom calls. Thematic analysis was used to perform qualitative analysis and identify major themes.

RESULTS

The sample comprised 21 AYAs who had genetic counseling and nine who did not. Motivational factors identified included learning genetic counseling is an available service, concern about the impact of a hereditary syndrome on family members and family planning, learning about the need for cancer screening or prevention, affordability of genetic testing, and easing worry about additional cancer risks. For those who did not pursue genetic counseling, barriers included scheduling or other priorities, worry, and cost. However, the majority expressed they would reconsider genetic counseling in the future.

CONCLUSION

AYA cancer patients have similar motivational factors to pursue genetic counseling compared to other patients; however, their younger age of diagnosis may alter how these factors affect decision-making. While there are barriers limiting access to genetic services, they did not decrease interest in future genetic counseling for most patients. Genetic counseling and testing should be discussed with patients who previously declined genetic services.

Perceived Susceptibility and Severity of COVID-19 on Prevention Practices, Early in the Pandemic in the State of Florida

Early in the pandemic and prior to the development of the COVID-19 vaccine, prevention measures were promoted to help inhibit the spread of the virus. To optimize adherence to prevention practices, it’s important to understand factors that may influence adherence. A study was conducted in the month of April, 2020, to explore the influence of perceptions of COVID-19 on prevention practices. The sample included members of a public social-media group focused on providing updates and information on COVID-19. A total of 719 individuals completed an online survey that assessed various aspects of COVID-19 which included experience, perceptions, and prevention practices. The perceptions of COVID-19 included perceived susceptibility of contracting the virus, and perceived potential severity if contracted COVID-19. To assess prevention practices, the survey included a 10-item prevention practices questionnaire that included items such as wearing a mask, and social distancing. Results revealed that perceived susceptibility of contracting COVID-19, and potential severity of COVID-19 were significant in predicting prevention practices. Further, results suggest that perceived potential severity predicts a greater proportion of the variance in prevention practices than susceptibility of contracting COVID-19. In addition, a moderation analysis revealed no interaction between perceived susceptibility and severity, which provides evidence that the variables do not influence one another. Theoretical and practical implications are discussed.

Attitudes towards social distancing in response to COVID-19

OBJECTIVES

COVID-19 has highlighted differences in our engagement in health prevention behaviors. The Health Belief Model (HBM), personality traits (conscientiousness, extraversion, and neuroticism), and sociodemographic variables were used to evaluate social distancing during the first month of a state-mandated Stay At Home (SAH) order.

DESIGN

A web-based convenience sample of 645 Ohioans was surveyed. Hierarchical linear regression and mediation analysis were used to examine predictors of social distancing attitudes and behaviors and whether health beliefs mediated the relationship between personality and social distancing.

RESULTS

Most respondents agreed with and adhered to social distancing guidelines. HBM constructs were strong predictors of SAH attitudes, while personality accounted for little additional variance. Anxiety was indirectly related to overall social distancing attitudes and behavior through its relationship with health beliefs. However, violations of social distancing were best explained by situational factors (e.g., being an essential worker).

CONCLUSION

The results demonstrate the power of components of the HBM to explain attitudes and behaviors regarding the SAH order beyond any contribution from personality. By examining the role of personality and health beliefs on social distancing attitudes and behaviors, this research will benefit public health nurses and others tasked with communicating and promoting preventative health behavior.

Adherence to Antihypertensive Medication: An Interview Analysis of Southwest Ugandan Patients' Perspectives

Background:

Hypertension is a significant cardiovascular disease (CVD) and driver to CVD disorders in sub-Saharan Africa. It is a major independent risk factor for heart failure, stroke, and kidney failure. Persons living with hypertension attend to many aspects of self-care to manage their condition, including high blood pressure medication adherence to control of blood pressure. Rates of medication non-adherence, and thus uncontrolled hypertension, remain high and contribute to poor health outcomes. Understanding barriers and facilitators to adherence to hypertension therapies can help improve health outcomes.

Objective:

The aim of the study was to describe the common reasons for adherence and non-adherence to antihypertensive medication from patients’ perspectives.

Methods:

A qualitative study engaged clients of an out-patient clinic of a regional referral hospital in southwestern Uganda who were living with hypertension as participants. One-on-one in-depth interviews provided the narrative data. The interview transcripts were analyzed using thematic analysis.

Findings:

Sixteen participants provided the data for the findings. The themes identified as facilitators for adherence to antihypertensive medication were patients’ understanding of prescribed medication, availability of medication for hypertension, family support for patients living with hypertension, and regular review appointments at the hypertensive clinics. Conversely, lack of supply in government dispensaries, use of self-prescribed analgesic medication, and stigma were identified as barriers and challenges of adherence to antihypertensive medication.

Conclusions:

There is an urgent need for the health ministry to improve availability of high blood pressure medication and for health care providers to deliver individualized patient centered care, and sensitization on danger of self-prescription and measures that reduce stigma. These strategies may improve adherence to high blood pressure medication.

Development of an inventory to assess perceived barriers related to PKU treatment

BACKGROUND

According to studies of phenylketonuria (PKU), the Brazilian population's metabolic control shows unsatisfactory indexes from childhood. Research on patients' perceived difficulties or barriers to adherence to treatment can help us to comprehend how these outcomes are associated. The present study aimed to: (1) describe the development of an inventory for identifying the most frequent and relevant perceived barriers to PKU treatment from the perspective of patients, caregivers, and healthcare professionals; (2) evaluate certain psychometric characteristics of the new measure; and, (3) explore potential predictors (sociodemographic and medical characteristics) that may contribute to increasing the number of perceived barriers and examine whether the number of barriers is associated with the degree of adherence shown by the patient.

RESULTS

Participants in the study were 23 patients with PKU (M age = 18.0 years; SD = 7.3; range 6 to 34 years; 69% early-treated) in classical (n = 11) and mild (n = 12) form, and 11 caregivers. The inventory, developed to ascertain perceived barriers to treatment, was completed by patients (≥ 13 years) and caregivers of patients aged 6 to 17 years. Analyses were conducted to investigate whether barrier inventory scores were associated with adherence to treatment as measured by phenylalanine levels in patients' medical records. Scores on the inventory differed across the patient age groups: adolescents had lower scores (i.e. reported fewer barriers) compared with those of adults (U = 8.000, p = 0.008); patients with better recent metabolic control also reported fewer perceived barriers than did patients with poor adherence (U = 20.000, p = 0.009); and the number of perceived barriers was positively associated with recent blood phenylalanine concentration (Kendall's taub = 0.41; p = 0.001).

CONCLUSIONS

These results suggest that the inventory has merit in assessing perceived barriers and support the need for further research on barriers perceived by PKU patients.

The use of discrete choice experiments in adherence research: A new solution to an old problem

Theory can play an important role in providing the framework, and underpinning the design and implementation of interventions to improve medication adherence. Interventions that are grounded in a theory are relatively more effective in improving medication adherence than interventions which do not have a theoretical support. However, a large body of adherence research does not appear to be linked to any theory or model, which therefore may have resulted in interventions that are either ineffective or not sustainable. Interventions that are based on theory have mainly employed socio-behavioural models to explain, and design interventions to address, the complex phenomenon of adherence. Yet, the effectiveness of these interventions is inconclusive, supporting the argument that socio-behavioural models alone have limited applicability in explaining behaviour associated with medication-taking. An important reason for this limitation may be the complex and dynamic nature of adherence. There is a need to include a wide variety of factors in a model and examine adherence in the context of its three phases (initiation, implementation, and discontinuation). One possible way forward is to also examine medication-taking behaviour from an economic perspective, for example, by using a discrete choice experiment (DCE), which provides a different approach to understanding human behaviour about medication-taking and the complexities of decision-making in adhering to medication. DCEs can help in understanding how patients decide to initiate, continue or discontinue taking medication, factors that influence their decision, and the relative importance of those factors, which can assist researchers to prioritise interventions to improve medication adherence. Integration of multiple theories is needed to examine adherence from multiple perspectives and design interventions that are effective and sustainable. This commentary focusses on the pros and cons of some of the commonly used socio-behavioural models in adherence research and suggests a way forward by incorporating DCEs in adherence research.

Predictors of adherence to positive airway pressure therapy in children: a systematic review and meta-analysis

BACKGROUND

While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children.

METHODS

Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed.

RESULTS

We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence.

CONCLUSION

In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.

Association Between Childhood Behavioral Problems and Insomnia Symptoms in Adulthood

Importance

Life-course determinants of insomnia, particularly the long-term association of childhood behavioral problems with insomnia later in life, are unknown. As childhood behaviors are measurable and potentially modifiable, understanding their associations with insomnia symptoms may provide novel insights into early intervention strategies to reduce the burden.

Objective

To investigate the association between behavioral problems at 5, 10, and 16 years of age and self-reported insomnia symptoms at 42 years of age.

Design, Setting, and Participants

This cohort study used data from the United Kingdom 1970 Birth Cohort Study, an ongoing large-scale follow-up study. Participants were followed up from birth (1970) to age 42 years (2012). Missing data were imputed via multiple imputation. Statistical analysis was performed from February 1 to July 15, 2019.

Exposures

Behavior measured at 5, 10, and 16 years of age using the Rutter Behavioral Scale (RBS). Children's behavior was classified as normal (≤80th percentile), moderate behavioral problems (>80th to ≤95th percentile), and severe behavioral problems (>95th percentile) based on their RBS score.

Main Outcomes and Measures

Self-reported difficulties initiating or maintaining sleep (DIMS) were collected using a self-administered questionnaire at 42 years of age. Log-binomial logistic regression, adjusted for several potential confounders, was used to estimate the association of childhood behavioral problems with insomnia symptoms in adulthood. Sensitivity analyses were conducted to check robustness of the findings.

Results

Participants were followed up from a baseline age of 5 years (n = 8050; 3854 boys and 4196 girls), 10 years (n = 9090; 4365 boys and 4725 girls), or 16 years (n = 7653; 3575 boys and 4078 girls) until age 42 years. There was a 39% higher risk of DIMS (odds ratio [OR], 1.39; 95% CI, 1.04-1.84; P = .06 for trend) for participants with severe behavioral problems at 5 years of age compared with those with a normal RBS score. The odds of DIMS plus not feeling rested on waking (DIMS plus) in participants with severe behavioral problems at 5 years of age were 29% higher (odds ratio, 1.29; 95% CI, 0.97-1.70; P = .14 for trend) than participants with a normal RBS score, although this result was not statistically significant. Moderate and severe behavioral problems at 16 years of age were positively associated with DIMS and DIMS plus (moderate: OR, 1.28; 95% CI, 1.07-1.52; severe: OR, 1.67; 95% CI, 1.22-2.30; P < .001 for trend) and DIMS plus (moderate: OR, 1.32; 95% CI, 1.11-1.56; severe: OR, 1.47; 95% CI, 1.09-1.98; P < .001 for trend). Externalizing behavioral problems at 5 and 10 years of age were positively associated with insomnia symptoms at 42 years of age.

Conclusions and Relevance

This study is the first to show associations of early-life behavioral problems, particularly early- and middle-childhood externalizing problems, with insomnia symptoms in adulthood. These findings underline the importance of addressing insomnia from a life-course perspective and considering the benefits of early behavioral intervention to sleep health.

Factors Associated with Parents' Adherence to Different Types of Exercises in Home Programs for Children with Disabilities

There is a lack of knowledge with regard to the adherence to different types of exercises prescribed for children with disabilities. The aim was to examine parents' adherence to prescriptions of different types of home exercises; to identify associated factors related to the parents, the children and the environment, and to assess the relative influence of the behaviour of health professionals. Parents (393) were recruited from 18 early intervention centres. A cross-sectional survey using a self-reported questionnaire was used to examine whether three types of exercises ("flexibility exercises", "neuromotor development training" and "body mechanics and postural stabilisation") were prescribed in their home programs; if the child had received exercises according to a prescription; and items related to the parents, child, environment, and health professionals. The adherence rates were different among the types of exercises. Parents with low perception of barriers and high self-efficacy had a higher adherence to neuromotor development training and postural stabilization, whereas parents with a high level of knowledge increased their odds of adherence to flexibility exercises. Health professionals' behaviour had a distinct influence on the adherence to different exercises. This study suggests the need to specifically consider the types of exercises prescribed in the management of adherence to home programs.

Adherence to long-term therapies in cystic fibrosis: a French cross-sectional study linking prescribing, dispensing, and hospitalization data

BACKGROUND

Cystic fibrosis (CF) is a life-shortening genetic condition that usually affects several organs and involves significant treatment burden. Adherence to medication is important for successful CF management.

OBJECTIVE

To describe medication adherence according to age, therapeutic class, and pharmaceutical form in adults and children followed in four regional CF centers in France.

METHODS

We conducted a cross-sectional study with non-transplanted patients followed in two adult and two pediatric centers during 2015 who were covered by the French National Health Insurance (NHI). Sociodemographic, clinical, hospitalization, and prescription data were collected from patient medical records. Medication dispensations were extracted from the regional French NHI database. Adherence was calculated over 12 months using continuous medication availability (CMA) accounting for dose adjustments and hospitalizations. Drug-specific CMA was computed in R with the AdhereR package for each medication prescribed more than 3 months, which was averaged to obtain a composite CMA score (cCMA) for all treatments and per therapeutic class as well as pharmaceutical form for each patient.

RESULTS

A total of 228 patients were included. The number of chronic medications increased with age (r=0.50, p<0.001): a median of 7 medications per patient were prescribed. The mean±SD cCMA was significantly different between age groups (p=0.0098): it was 0.71±0.20 for the 0-5 years age group, 0.73±0.16 for 6-11 years, 0.64±0.17 for 12-17 years, 0.57±0.23 for 18-25 years, and 0.65±0.20 for the over 25 years age group. cCMA varied significantly according to pharmaceutical forms: the mean±SD cCMA was 0.70±0.21 for oral medications and 0.54±0.28 for inhaled medications (p<0.001).

CONCLUSION

This study suggests that adherence to medication regimens in CF patients remains suboptimal and varies substantially between age groups and pharmaceutical forms. These variations in adherence should be considered when developing effective strategies to improve adherence.