The effect of a token economy on dietary compliance for children on hemodialysis

Integration of art and technology in personalized radiation oncology care: Experiences, evidence, and perspectives

Cancer diagnoses expose patients to traumatic stress, sudden changes in daily life, changes in the body and autonomy, with even long-term consequences, and in some cases, to come to terms with the end-of-life. Furthermore, rising survival rates underline that the need for interventions for emotional wellbeing is in growing demand by patients and survivors. Cancer patients frequently have compliance problems, difficulties during treatment, stress, or challenges in implementing healthy behaviors. This scenario was highlighted during the COVID-19 emergency. These issues often do not reach the clinical attention of dedicated professionals and could also become a source of stress or burnout for professionals. So, these consequences are evident on individual, interpersonal, and health system levels. Oncology services have increasingly sought to provide value-based health care, considering resources invested, with implications for service delivery and related financing mechanisms. Value-based health care can improve patient outcomes, often revealed by patient outcome measures while seeking balance with economical budgets. The paper aims to show the Gemelli Advanced Radiation Therapy (ART) experience of personalizing the patients' care pathway through interventions based on technologies and art, the personalized approach to cancer patients and their role as "co-stars" in treatment care. The paper describes the vision, experiences, and evidence that have guided clinical choices involving patients and professionals in a co-constructed therapeutic pathway. We will explore this approach by describing: the various initiatives already implemented and prospects, with particular attention to the economic sustainability of the paths proposed to patients; the several pathways of personalized care, both from the patient's and healthcare professional perspective, that put the person's experience at the Gemelli ART Center. The patient's satisfaction with the treatment and economic outcomes have been considered. The experiences and future perspectives described in the manuscript will focus on the value of people's experiences and patient satisfaction indicators, patients, staff, and the healthcare organization.

Music therapy in pediatric asthma improves pulmonary function while reducing hospitalizations

Objective: The aim of this study was to evaluate music therapy (MT), in conjunction with standard care, as a complementary option for asthma management in pediatric patients.Methods: 173 children were randomly assigned to one of three groups: 1) Music: a single individualized MT session along with a recorder and journal with instructions for home use; 2) Music Plus: weekly group MT sessions along with a recorder and journal for home use; or 3) Control: standard of care. Primary endpoints included pulmonary function tests (FEV1, FVC, FEF25-75, PEF), hospitalizations, ER visits, missed school days, and quality of life (Juniper).Results: Significant intergroup differences relative to Controls were observed for FEV1/FVC (Music and Music Plus, p < 0.05) and FEF25-75 (Music Plus; p < 0.01). Music Plus participants experienced fewer hospitalizations compared to Controls (p < 0.001), corresponding to 1.16 fewer hospitalizations per patient-year. Caregivers' perception of their children's QOL significantly increased in the Music (p = 0.011) and Music Plus (p < 0.001) groups compared to Controls.Conclusion: These results reflect MT's potential to favorably impact pediatric asthma management as a child-friendly, low-risk intervention. Further research is needed to substantiate the possible benefits of incorporating MT into standard treatment regimens.

Health and Nutrition Literacy and Adherence to Treatment in Children, Adolescents, and Young Adults With Chronic Kidney Disease and Hypertension, North Carolina, 2015

Introduction

Adherence to treatment and dietary restrictions is important for health outcomes of patients with chronic/end-stage kidney disease and hypertension. The relationship of adherence with nutritional and health literacy in children, adolescents, and young adults is not well understood. The current study examined the relationship of health literacy, nutrition knowledge, nutrition knowledge–behavior concordance, and medication adherence in a sample of children and young people with chronic/end-stage kidney disease and hypertension.

Methods

We enrolled 74 patients (aged 7–29 y) with a diagnosis of chronic/end-stage kidney disease and hypertension from the University of North Carolina Kidney Center. Participants completed instruments of nutrition literacy (Disease-Specific Nutrition Knowledge Test), health literacy (Newest Vital Sign), nutrition behavior (Nutrition Knowledge–Behavior Concordance Scale), and medication adherence (Morisky Medication Adherence Scale). Linear and binary logistic regressions were used to test the associations.

Results

In univariate comparisons, nutrition knowledge was significantly higher in people with adequate health literacy. Medication adherence was related to nutrition knowledge and nutrition knowledge–behavior concordance. Multivariate regression models demonstrated that knowledge of disease-specific nutrition restrictions did not significantly predict nutrition knowledge–behavior concordance scores. In logistic regression, knowledge of nutrition restrictions did not significantly predict medication adherence. Lastly, health literacy and nutrition knowledge–behavior concordance were significant predictors of medication adherence.

Conclusion

Nutrition knowledge and health literacy skills are positively associated. Nutrition knowledge, health literacy, and nutrition knowledge–behavior concordance are positively related to medication adherence. Future research should focus on additional factors that may predict disease-specific nutrition behavior (adherence to dietary restrictions) in children and young people with chronic conditions.

Dietary adherence in children with chronic kidney disease: a review of the evidence

BACKGROUND

In children with chronic kidney disease (CKD), a nutrition support plan is important to ensure optimal macro- and micro-nutrient intake in order to avoid malnutrition, disease-related complications and growth rate reduction. Children with CKD and their families encounter many difficulties in adjusting to the renal diet. Even though adherence to the recommended dietary plan is important in CKD, it is rarely measured partly due to the lack of robust, unbiased assessment methods.

METHODS

In this review of 22 papers, the techniques used to assess adherence in children with CKD are reviewed, alongside their advantages and disadvantages.

FINDINGS

Although dietary surveys, biochemical index assessment and clinician ratings have been found not to be efficient when used as a single tool, they should be used in combination in order to give the opportunity to the health providers to perceive adherence from as many angles as possible.

Promoting Medication Adherence and Regimen Responsibility in Two Adolescents on Hemodialysis for End-Stage Renal Disease

Medication adherence and regimen responsibility (RR) have important implications for adolescents with hemodialysis-dependent end-stage renal disease (ESRD). This case study assesses the preliminary efficacy of a cognitive-behavioral intervention to promote medication adherence and RR in two African American adolescents. Two patients and their mothers participated. Intervention modules addressed adherence barriers. Using a case-series design, weekly parent–adolescent reports of medication adherence and RR were collected. The female participant’s selective nonadherence improved during treatment. Mother and daughter were high in RR throughout the study. The male participant’s adherence initially decreased following his mother’s reduced involvement in treatment. His adherence improved by the end of treatment, and coincided with his mother’s reassumption of RR. Improvements were maintained through follow-up for both patients. This case study provides preliminary support for using a cognitive-behavioral protocol to improve medication adherence in adolescents with hemodialysis-dependent ESRD.

Is the learn unit a fundamental measure of pedagogy?

We propose a measure of teaching, the learn unit, that explicitly describes the interaction between teachers and their students. The theoretical, educational research, and applied behavior analysis literatures all converge on the learn unit as a fundamental measure of teaching. The theoretical literature proposes the construct of the interlocking operant and embraces verbal behavior, social interaction, and translations of psychological constructs into complex theoretical respondent-operant interactions and behavior-behavior relations. Research findings in education and applied behavior analysis on engaged academic time, opportunity to respond, active student responding, teacher-student responding, student-teacher responding, tutor-tutee responding, tutee-tutor responding, and verbal episodes between individuals all support a measure of interlocking responses. More recently, research analyzing the components of both the students' and teachers' behavior suggests that the learn unit is the strongest predictor of effective teaching. Finally, we propose applications of the learn unit to other issues in pedagogy not yet researched and the relation of learn units to the verbal behavior of students.

Sticker charts: a method for improving adherence to treatment of chronic diseases in children

Poor adherence is a common problem and may be an underlying cause of poor clinical outcomes. In pediatric populations, positive reinforcement techniques such as sticker charts may increase motivation to adhere to treatment regimens. To review the use of sticker charts to improve adherence in children with chronic disease, Medline and PsycINFO searches were conducted using the key words "positive reinforcement OR behavior therapy" and "adherence OR patient compliance" and "child." Randomized controlled retrospective cohort or single-subject-design studies were selected. Studies reporting adherence to the medical treatment of chronic disease in children using positive reinforcement techniques were included in the analysis. The systematic search was supplemented by identifying additional studies identified through the reference lists and authors of the initial articles found. Positive reinforcement techniques such as sticker charts increase adherence to medical treatment regimens. In several studies, this effect was maintained for months after the initial intervention. Better adherence correlated with better clinical outcomes in some, but not all, studies. Few studies examining the use of sticker charts were identified. Although single-subject-design studies are useful in establishing the effect of a behavioral intervention, larger randomized controlled trials would help determine the precise efficacy of sticker chart interventions. Adherence to medical treatments in children can be increased using sticker charts or other positive reinforcement techniques. This may be an effective means to encourage children with atopic dermatitis to apply their medications and improve clinical outcomes.

Adherence to antibiotic prophylaxis in children with vesicoureteral reflux

Vesicoureteral reflux (VUR) affects approximately 1% of children and may predispose a child with a bladder infection to develop pyelonephritis and renal scarring. To prevent these potential sequelae, one accepted treatment option for VUR includes low-dose continuous antibiotic prophylaxis (CAP) to maintain urine sterility until the condition resolves. Despite the widespread use of CAP, little data exists regarding adherence to long-term antibiotic therapy. Not only will poor adherence to CAP potentially preclude the intended benefit, but also nonadherence with antibiotic regimens may carry untoward effects including unnecessary treatment changes for presumed antibiotic failure, emergence of resistant organisms, and compromised clinical trial outcomes. We present an overview of medication adherence in children with VUR, discuss possible consequences of nonadherence to antibiotic prophylaxis, and suggest ways to improve adherence. We raise awareness of issues related to nonadherence relevant to healthcare providers, investigators, and the community.

Review of Adherence-Related Issues in Adolescents and Young Adults With Cancer

Purpose

This review aims to provide a broad overview of the issues and clinical challenges of nonadherence in adolescents and young adults (AYAs) with cancer. Nonadherence can reduce treatment efficacy, which places the patient at higher risk of relapse, adverse effects, and poor outcomes.

Design

A review of the English-speaking literature between 1980 and 2008 was conducted to identify relevant publications, which were supplemented by reference and author searches.

Results

Definition and measurement of adherence varies. Most studies have not clearly delineated an AYA age group (ie, 15-25 years) and have been dominated by leukemia and lymphoma samples. Estimates for nonadherence in this population range from 27% to 60%, with openness of family relationships and support found to predict adherence. Strategies to avoid, assess, and manage nonadherence are presented.

Conclusion

Overall, the evidence base for adherence and strategies to promote it in AYAs with cancer is woefully lacking. There is a need for high-quality studies that target clinically important questions, randomized controlled trials of theoretically based interventions, and development and evaluation of training programs for oncology staff in the special issues faced by AYAs with cancer.

Meta-analysis of psychological interventions to promote adherence to treatment in pediatric chronic health conditions

OBJECTIVE

To estimate the effectiveness of adherence-promoting psychological interventions for pediatric populations with chronic health conditions.

METHODS

A meta-analysis was conducted on 70 adherence-promoting psychological intervention studies among chronically ill youth using a weighted least squares approach and random effect model.

RESULTS

Medium effects sizes were found for the behavioral (mean d =.54, 95% confidence interval [CI] = 0.34-0.73, n = 10) and multi-component interventions (mean d =.51, 95% CI = 0.45-0.57, n = 46), while educational interventions displayed a small effect size with adherence (mean d =.16, 95% CI = 0.10-0.22, n = 23). Study designs incorporating pre-post comparisons yielded effect sizes approaching the medium range (mean d =.42, 95% CI = 0.36-0.48, n = 30).

CONCLUSIONS

Behavioral and multi-component interventions appear to be relatively potent in promoting adherence among chronically ill youth. Recommendations for future research and methodological issues are presented.

A systematic review of psychological interventions for the treatment of nonadherence to fluid-intake restrictions in people receiving hemodialysis

BACKGROUND

Psychological interventions aimed at improving adherence to fluid-intake restrictions in patients receiving hemodialysis have become increasingly common. To the authors' knowledge, this is the first systematic review of the literature examining the impact of these interventions associated with patient interdialytic weight gain (IWG).

METHODS

A systematic search of the literature was performed on EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PsychINFO. The search was augmented by manually examining reference lists of reviews and retrieved reports. Study quality was graded according to criteria developed by the authors. Two additional independent researchers separately coded a random sample of studies to avoid bias of rating.

RESULTS

Sixteen studies were identified as eligible for inclusion. Relevant information from each included study was extracted and entered into a standardized table. Nearly all studies showed a postintervention decrease in IWG. A number of method weaknesses in the existing literature were identified.

CONCLUSION

Studies investigating psychological interventions aimed at improving adherence to fluid-intake restrictions appear to indicate some success in decreasing IWG. However, confidence regarding the validity of this finding is circumscribed by the prevalent use of investigative designs with inherently high susceptibility to bias. Future studies would benefit from using larger numbers of participants within controlled designs. Clearer description of intervention protocols would foster greater understanding of the contextual appropriateness of different approaches and which treatment components are key to improving adherence to fluid-intake restrictions in patients receiving hemodialysis.

Using a pants alarm for the treatment of day wetting: problems with compliance

A treatment of day wetting was evaluated in four normally capable children (ages 4:9, 4:10. 6:3, and 10:1 years). The treatment combined the use of a pants alarm with rewards (praise and tokens) for urinating in the toilet. The treatment was effective for one child only. The others showed many instances of noncompliance (not wearing the alarm, wearing the alarm with loose contacts or with the contacts on places where they could not detect urine). Tactics for dealing with this are suggested.

Transplant allograft loss in the adolescent patient

The case of an adolescent transplant recipient who lost her allograft as a result of medication noncompliance serves as the focus of this multidisciplinary review. The discussion that follows includes (1) a review of current graft survival data for adolescent renal transplant recipients with particular attention to the occurrence of medication noncompliance in this patient population, (2) an overview of normal growth and development as it applies to the adolescent patient with chronic disease, and (3) proven treatment strategies with emphasis on the needs of the adolescent transplant patient. The discussion is intended to provide the reader with a greater understanding and appreciation of developmental issues that influence adolescent behavior and, in turn, impact medical care. It is also hoped that the information provided will be used by health care providers to promote adherence to a chronic medical regimen on behalf of the adolescent transplant recipient.

Use of a token economy to increase compliance during hemodialysis

We report the effects of using a token economy to treat noncompliant behavior in a 10-year-old male hemodialysis patient. The results of an ABAB design indicated that the intervention increased compliant behavior during both treatment phases and that compliance was maintained at 3- and 6-month follow-up observations.

Contingent social reinforcement for fluid compliance in a hemodialysis patient

Two approaches, (a) patient education and (b) compliance-contingent social reinforcement, were employed to improve compliance with fluid restrictions in a chronically noncompliant hemodialysis patient of borderline intellectual functioning. Results indicated that only social reinforcement led to improved compliance (i.e., decreased intersession weight gain). Treatment effects were well maintained at both 3- and 6-month follow-ups. Contingency management strategies are recommended as a potentially cost effective treatment for noncompliance in hemodialysis patients.

A behavioral prescription for promoting applied behavior analysis within pediatrics

In recent decades, pediatric medicine has undergone a shift in focus from infectious diseases to the effects of behavior on the health and development of children. At the same time, behavior analysts have increasingly evaluated the direct application of their technology to the development and maintenance of child health behavior. Unfortunately, applied behavior analysts have developed their technology parallel to, rather than collaboratively with, pediatricians and, as a result, are not recognized as experts in the treatment of child health behavior. In addition, behavioral technology is not widely recognized as the treatment of choice by pediatricians. This paper provides a behavioral prescription for behavior analysts who wish to enter pediatrics as expert scientists and technicians. Specific recommendations are provided for stimulating collaborative rather than parallel development between applied behavior analysis and pediatrics in the promotion and maintenance of child health behavior. Strategies for maintaining this collaborative relationship and for strengthening the social relevance of behavior analysis are discussed.

Compliance with treatment regimens for pediatric rheumatic diseases

Children with pediatric rheumatic diseases (PRDs) are required to comply with long-term treatment regimens that may not have immediate beneficial effects or may be required primarily to prevent further morbidity. As with other chronic disease regimens, compliance can be a significant problem that interferes with treatment efficacy and adequate clinical outcomes. This paper reviews (1) the prevalence and types of compliance problems in the management of PRDs; (2) patient/family, disease, and regimen factors that may be associated with treatment noncompliance; and (3) strategies for improving compliance with regimens for PRDs.

Promoting adolescents' compliance with therapeutic regimens

Noncompliance in the adolescent is a difficult problem that can be prevented or improved. It is best identified early by nonjudgmental questioning about current or previous regimen behavior. An appreciation of the relevant psychological and social issues can suggest to the clinician which adolescents are at high risk for noncompliance. Intervention techniques based on educational and psychological principles can be successfully applied by the physician to improve compliance and can improve the teenager's sense of mastery. Personal characteristics of the physician, however, may determine whether he or she can work productively with the noncompliant adolescent.

Patient compliance behavior: the effects of time on patients' values of treatment regimens

Present medical models of treatment compliance have not addressed the role that time plays in the perception of a treatment regimen's costs and benefits. This paper re-evaluates the role of time in understanding compliance behavior. Models from the economic and psychological literature are used to demonstrate that the 'discounting effect' associated with future events, and the 'sunk cost effect' associated with past events may have a direct and predictable impact on the patient's values in health care choices. This article suggests that when the effects of time are incorporated into expectancy models of compliance behavior (such as the Health Belief Model) the resulting predictions are supported by numerous findings in the compliance literature, many of which were previously unaccountable by these expectancy models. From this finding an explanation is derived for the variable results of educational and attitudinal change programs upon compliance behavior, the success of patient contracts, the sudden occurrence of preference reversals in health care choices, and the 'confusing' effect of treatment cost on treatment adherence. This paper also introduces to the compliance literature the concept of a treatment's 'time adjusted rate of return', and speculates upon how this concept may be used to understand the relationship between a treatment's 'desirability' or its ability to motivate a person to start the treatment, and its 'resistance' or its capacity to help a person to finish the treatment once it has begun. It proposes that changes in the temporal distribution of a treatment's benefits and costs can improve the treatment's desirability and resistance, and that a treatment's time adjusted rate of return can be used to allocate more efficiently the effort that providers spend monitoring patient compliance.

Treatment of an abnormal avoidance of fluid consumption

Adipsia is an uncommon, life-threatening condition which refers to an absence of thirst or an abnormal avoidance of fluid consumption. A behavioral intervention was successfully used in the treatment of severe adipsia in a multi-handicapped adolescent whose water intake was almost entirely limited to the water content of the foods he consumed. Using edible reinforcement and a set of commercial measuring utensils (from 1/4 teaspoon to 1 cup), milk consumption was established through a behavior shaping regimen. Follow-up results over 1 year indicated that the behavioral progress was maintained, problems with dehydration were eliminated, and stimulus generalization to several other fluids occurred.

Intervention strategies to improve compliance with medical regimens by ambulatory hemodialysis patients

This research examined the relative efficacies of three intervention strategies designed to increase compliance to medical regimens in a group of ambulatory hemodialysis patients. The interventions examined included behavioral contracting (with or without the involvement of a family member or friend) and weekly telephone contacts with patients. Compliance was assessed with regard to following dietary restrictions and limiting fluid intake. Data were collected from 116 patients drawn from two outpatient clinics. Within clinics, patients were randomly assigned either to an intervention program or to a control group. The study employed a pretest-posttest control group design. Patients were interviewed before the intervention programs began (T1), after a 6-week intervention period (T2), and 3 months after completion of the intervention period (T3). Results showed that the interventions achieved substantial reductions in patients' serum potassium levels and in weight gains between dialysis treatments between T1 and T2. In general, however, these program effects tapered off to preintervention levels between T2 and T3. The findings thus indicate a need for long-term intervention programs.

Strategies for enhancing patient compliance

Patient noncompliance is a substantial obstacle to the achievement of therapeutic goals. This paper reviews a number of practical interventions with demonstrated efficacy in enhancing patient adherence, including (1) improving patients' levels of information concerning the specifics of their regimens, reinforcing essential points with review, discussion, and written instruction, and emphasizing the importance of the therapeutic plan, (2) taking clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through "tailoring" and other approaches, (3) obtaining a compliance-oriented history of the patient's prior experiences and present health beliefs and, where necessary, employing strategies to modify those perceptions likely to inhibit compliance, (4) improving levels of patient satisfaction, particularly with the provider-patient relationship, (5) arranging for the continued monitoring of the patient's subsequent compliance to treatment, (6) increasing staff awareness of the magnitude and determinants of the noncompliance phenomenon and attempting to develop an "active influence orientation" in each member of the health care team, (7) using such techniques as patient-provider contracts to involve the patient in therapeutic decisions and in the setting of treatment objectives and creating incentives (through rewards and reinforcements) for achieving these objectives, (8) arranging for as much continuity of provider (and other staff) as possible, (9) establishing methods of supervising the patient, including involvement of the patient's social support network, and (10) involving fully the assistance of all available health care providers, assigning specific roles and responsibilities for activities directed at improving adherence to treatment.

The use of behavior modification techniques for the treatment of hemodialysis patient non-compliance: a case study

This study concerns a renal patient who was non-compliant to staff requests to monitor his blood clotting times. The non-compliant behavior was resolved within six treatment sessions through the combined use of contracting, shaping, stimulus control, discrimination training and social and material reinforcement. Follow-ups at 30, 60 and 90 days revealed a high degree of patient compliance and accuracy in taking and recording his blood clotting times. Implications for behavior modification techniques in the field of hemodialysis are briefly discussed.