Guided asthma self-management or patient self-adjustment? Using patients' narratives to better understand adherence to asthma treatment

Short-acting β2-agonists (SABA) overuse in asthma and patients' perceptions for this behavior

BACKGROUND

Short-acting β2-agonists (SABA) overuse is associated with poor asthma control. The Global Initiative for Asthma (GINA) 2019-updated strategy report has therefore taken a paradigm shift in reliever therapy recommendations.

OBJECTIVES

(I) To investigate the status of SABA overuse and medication dispensing patters in asthma in the Netherlands (II) validate dispensing data for SABA overuse identification and (III) understand patients' perspectives towards this SABA-taking behavior to inform future improvement strategies.

METHODS

An annually repeated cross-sectional study was conducted from 2017 to 2021 using pharmacy dispensing data in a real-world setting, including asthma patients aged 18-45 with ≥1 inhaler. A following qualitative study was performed in identified SABA overusing patients with a questionnaire and semi-structured interviews, supported by theoretical frameworks.

RESULTS

Dispensing data was available from 87 % of all community pharmacies (n = 1994) in 2017 and 95 % (n = 2005) in 2021. SABA overuse prevalence was constant for the five study-years with 20.6 % (±0.5 %). Increased ICS-formoterol and decreased SABA dispenses were observed in starters of inhalation therapy in 2021. 53 asthma patients completed the questionnaire of whom 43 patients confirmed SABA overuse, generating a positive predictive value of 81 %. Key behavioral drivers covered 7 themes regarding capability (knowledge; skills; memory, attention and decision process) motivation (emotion; beliefs about-capabilities; consequences) and opportunity (environmental context).

CONCLUSION

SABA overuse remains in one-fifth of asthma patients across the Netherlands, requiring careful attention from healthcare professionals. Dispensing data is a valid measure for SABA overuse in a clinical setting, facilitating patient selection. To meet patients' varied supporting needs, integration of tailored behavioral interventions is essential.

Targeting Asthma Remission as the Next Therapeutic Step Toward Improving Disease Control

The long-term goal of asthma management is to achieve disease control, comprising the assessment of 2 main domains: (1) symptom control and (2) future risk of adverse outcomes. Decades of progress in asthma management have correlated with increasingly ambitious disease control targets. Moreover, the introduction of precision medicines, such as biologics, has further expanded the limits of what can be achieved in terms of disease control. It is now believed that clinical remission, a term rarely associated with asthma, may be an achievable treatment goal. An expert framework published in 2020 took the first step toward developing a commonly accepted definition of clinical remission in asthma. However, there remains a widespread discussion about the clinical parameters and thresholds that should be included in a standardized definition of clinical remission. This review aims to discuss on-treatment clinical remission as an aspirational outcome in asthma management, drawing on experiences from other chronic diseases where remission has long been a goal. We also highlight the integral role of shared decision-making between patients and health care professionals and the need for a common understanding of the individual patient journey to remission as foundational elements in reducing disease burden and improving outcomes for patients with asthma.

Caregiver's sense of coherence and adherence to paediatric asthma treatment

Asthma is a chronic respiratory condition that needs to be well controlled to avoid compromising patients' quality of life. In the paediatric population, the role of caregivers is essential in this process. Moreover, adequate asthma control is integral to a child's emotional well-being and to improving the child's ability to participate fully in family and social life. One of the main reasons for uncontrolled asthma is low adherence to treatment, by patients and caregivers. Identifying factors mediating the involvement and participation of caregivers through evaluations of caregivers' sense of coherence can help in the adoption of strategies aimed at effectively directing adherence behaviour through educational and motivational interventions. The goal of this review article is to provide an overview of the sense of coherence as a construct of Antonovsky's salutogenic theory, and to identify its role as a key piece in the successful management of asthma in children.

Qualitative study of user perspectives and experiences of digital inhaler technology

Electronic monitoring devices (EMDs) have been trialled in interventions to improve inhaled corticosteroid adherence and clinical outcomes. This study sought to understand the perceptions and experiences of EMD end-users. Participants recruited into a six-month EMD study were invited to a semi-structured interview. Interviews were audio-recorded, transcribed verbatim and analysed using the framework approach. Twenty-eight participants (68% female, median age 47) were interviewed. Individuals described feeling responsible for their asthma control. Recent attacks motivated a desire to maintain control. Study participation led to increased awareness of asthma status and medication use. Several individuals were open to integrating digital monitoring data with other mHealth inputs, perceiving the potential to enhance communication with clinicians and empower self-management. Openness to data sharing was tied to expectations of transparent data use. Data supported integrating beliefs and habit formation to achieve behaviour change. There was a willingness for an integrated, platform-based approach to digital self-management.

'Between foods and medicines': A qualitative interview study of patient experiences of the meaning and usage of oral nutritional supplements

The aim of this study was to deepen the understanding of what oral nutritional supplements mean to patients and how this meaning connects to supplement usage, by exploring patient experiences of such supplements. Qualitative interviews were conducted in June 2019-March 2020 with ten patients with malnutrition or at nutritional risk, prescribed oral nutritional supplements by dietitians. Data were thematically analysed using systematic text condensation. Two final categories were identified: 'Oral nutritional supplements are a one-dimensional remedy' and 'Everyday oral nutritional supplement usage is regulated autonomously'. The patients described the meaning of oral nutritional supplements as nutrition. While the supplements could compensate for nutrients not eaten or be part of a helpful compensation strategy, they could not lessen the burden of altered eating. Supplement usage was described as dependent on the acceptance of taste and the priority given to nutrition in everyday life. Usage was greater when nutrients were perceived as needed, such as when striving for higher bodyweight or disease recovery. Usage was lower when a patient's own goals were not increased nutrient intake or bodyweight or when other activities were perceived as more important. Patient experiences indicated that oral nutritional supplements could serve as a remedy for malnutrition, but not for a situation of altered eating. Supplement usage was described as being regulated autonomously based on patient views on the importance of nutrition. Those views were diverse, highlighting the importance of supplement prescribers discussing treatment goals with each patient. A deeper understanding of the meaning of oral nutritional supplements and reasons for their usage from a patient perspective is crucial in order for healthcare to provide appropriate, effective nutrition therapy for malnutrition.

How do embodied experiences of asthma influence caregiver conceptual models?

RATIONALE

Many studies propose that patients', caregivers', and children's asthma management practices may diverge from biomedical recommendations because their understandings of asthma (i.e., conceptual models) are different from biomedical perspectives. However, little research in this area has examined conceptual models of asthma using embodiment theory, which suggests that caregivers' and children's experiences of the physical body shape their perspectives and consequent management strategies.

OBJECTIVE

We investigated how two embodied processes of symptom perception-detection and interpretation-may influence caregiver or patient conceptions of asthma.

METHODS

We interviewed 41 caregivers of children with asthma in Gainesville, Florida, and St. Louis, Missouri, and conducted ethnographic visits or virtual interviews with 19 children with asthma aged 6-16.

RESULTS

Four aspects of asthma's embodied experience shaped conceptual models via processes of detection and interpretation: 1) symptoms are experienced in the context of other bodily processes; 2) acute symptoms and exacerbations are more salient than their absence; 3) the embodied experience of asthma is one of integrated physiological and emotional processes; and 4) caregivers and children acquire embodied practices of perceiving symptoms that produce embodied knowledge.

CONCLUSION

Participant narratives suggest that embodied experiences of asthma shape caregivers' and children's understandings of asthma in ways that differ from the biomedical model. We argue that a focus on embodied experiences may provide important ground for mutual understanding and communication between providers and caregivers and/or patients.

Ethical considerations in pediatric chronic illness: The relationship between psychological factors, treatment adherence, and health outcomes

Children, adolescents, and young adults with chronic illnesses are often faced with complicated and burdensome treatments that not only require a great deal of time and energy to manage, but will also likely impact relationships with parents, siblings, and peers. Adolescents and young adults with chronic illness are often impacted by several unique and challenging factors that can ultimately impact health behaviors and treatment outcomes. Working with a psychologist can help to ameliorate these unique challenges, which will positively impact health behaviors and health outcomes. The present paper provides an overview of psychological interventions that were designed to target the unique challenges that are often associated with maladaptive health behaviors and ultimately poor health outcomes. As demonstrated in this commentary, when working with adolescents and young adults who have unique developmental challenges, it is important to deliver multi-faceted intervention approaches that utilize a number of different strategies and frameworks. These eclectic intervention approaches provide a unique opportunity to improve health behaviors during critical developmental periods, including the transition from childhood to adolescence to young adulthood.

[Narrative patterns in asthma and the challenge to accept the need for patient education]

BACKGROUND

The benefits of patient education in bronchial asthma in terms of reducing hospitalization and incapacity to work are well documented. However, only about a quarter of patients take advantage of training offers. Therefore, this qualitative study with asthma patients examines how to sharpen the motivation to participate in training programs.

METHODS

In order to investigate narrative patterns of chronic illness in asthma patients, we conducted 14 problem-centered narrative (telephone) interviews. The collected data were evaluated in accordance with system-theoretical analysis. This methodology allows for the interviews to be examined for their narrative patterns. The central question was how the patients we interviewed succeeded in constructing normality in the interviews.

RESULTS

From the analysis of the interviews, we were able to develop four types of narrative patterns: the chronic illness as a crisis (1), as a passion (2), as an odyssey (3), and as homeostasis (4). Within these forms of narration, the transition from normal to pathological is told in a specific and exemplary manner. The results of our study can be seen as a contribution to the dynamization and differentiation of trajectories of chronic disease.

DISCUSSION

We identified significant differences in the experienced trajectories of the disease. Patients are dealing with chronic disease in different styles, which have individual "pressure points" where motivation for adherence is created in the first place. The results show that the patient's knowledge structures unfolding in the narrative patterns should not be viewed as health illiteracy.

CONCLUSION

These typologies of the normal and the pathological do not only provide a key to understanding the life-world (Lebenswelt) of chronically ill people, but also to the question of what motivates chronically ill patients to participate in patient trainings. This in-depth understanding could help us to improve motivational discussions with these patients.

[Patient expectations in asthma care]

Asthma, a common chronic disease characterized by variable levels of severity, requires patient-centered management to achieve the best health outcomes. Studies have highlighted the gap between consensus management recommendations and patient goals, which represent a potential source of therapeutic wandering and of poor compliance. Patient expectations are continually evolving and are dependent on knowledge, feelings and individual experience. From this perspective, listening carefully to patients and caregivers makes it easier to exchange views and define common goals. The active participation of patients at all levels of decision-making and transmission of information may improve asthma control and other quality of life parameters.

Impact of the COVID-19 pandemic on asthma control among children: a qualitative study from caregivers' perspectives and experiences

OBJECTIVES

To understand the impact of the COVID-19 epidemic on asthma control in children based on caregivers' perspectives and experiences.

DESIGN

This was a qualitative study deploying face-to-face, semistructured interviews. Thematic analysis was carried out to analyse the data.

SETTING

Paediatric respiratory clinics in three tertiary hospitals.

PARTICIPANTS

16 caregivers providing unpaid asthma-related care and assistance to children under 14 years who had been diagnosed with asthma for more than 1 year and were not only treated with short-acting β2-agonists.

RESULTS

Six main themes were identified: (1) improved asthma control; (2) decreased willingness to seek medical care driven by fear; (3) increased adherence due to enhanced awareness of asthma control; (4) coping strategies for changes caused by COVID-19; (5) a new opportunity and (6) managing new challenges in asthma control.

CONCLUSIONS

The COVID-19 outbreak and the measures in response to it have had significant impacts on asthma control among children. Children with asthma are advised to continue good asthma management, take their prescribed asthma medications as normal, wash their hands regularly and wear face masks. Regularly supported self-management and remote consultations should be provided during the COVID-19 pandemic. In addition, supporting people financially, providing continued medical support and alleviating any fear and anxiety should be considered. We anticipate that our findings will inform health promotion interventions.

Physician's perspective regarding asthma guided self-management: directives or guidance?

INTRODUCTION

Asthma guided self-management enhances patients' control of their condition under the guidance of the treating physician. The aim of the present study was to understand how physicians perceive, endorse, uptake, and support asthma guided self-management.

METHODS

We conducted a secondary supplementary analysis of data originally collected as part of a multicenter collective case study in which physicians treating patients with asthma were interviewed. Using reflective thematic analysis, we aimed to explore physicians' understanding of guided asthma self-management as related to four ideas, namely: (a) understanding of the disease management and treatment goals; (b) defining medical frame and guidance; (c) describing the importance of patient-physician relationship; and (d) implementing asthma guided self-management.

RESULTS

Evidence indicates that physicians perceived optimal guided self-management as related to patients' adherence to physician's instructions and recommendations, supported by the adjustment of prescribed pharmaceutical therapy contingent upon patient's symptoms. Some physicians also perceived behavior change and environmental control along with the medical recommendations. While physicians' perception of asthma and its treatment were aligned with the recommended guidelines-i.e., patient-centered care approach based on guided self-management, the actual guidance offered to patients remained primarily directive and paternalistic. Non-pharmacological approaches, such as exercise, smoking cessation, patient self-monitoring, and self-management supported by education and written self-management plans, were given little consideration in the context of the recommended treatment plan.

Potential Role of the Micro-Immunotherapy Medicine 2LALERG in the Treatment of Pollen-Induced Allergic Inflammation

In this study, we evaluated the efficacy of a micro-immunotherapy medicine (MIM), 2LALERG, in a preclinical model of allergic respiratory disease sensitized with birch pollen extract (BPE). BALB/c mice were immunized with BPE, or saline solution, and were then challenged. Micro-immunotherapy medicine pillules were diluted in water, and 3 doses (0.75; 1.5; 3 mg/mouse) were tested and compared to vehicle control (3 mg/mouse). Treatments and vehicle were orally administered by gavage for 10 days. Micro-immunotherapy medicine (0.75 mg/mouse) reduced the number of total cells as well as the levels of interleukin (IL)-13 in bronchoalveolar lavage fluid (BALF) compared to vehicle control. Eosinophils in BALF tended to be lower compared to vehicle group, and the difference is close to significance. Histological analysis in the lungs confirms a moderate effect of MIM (0.75 mg/mice) on inflammatory infiltration and mucus production. Serum levels of IL-5 in MIM (0.75 mg/mouse)-treated mice were lower compared to vehicle; IL-4 levels tended to be lower too. Total immunoglobulin E (IgE) decreased in serum of MIM (1.5 and 0.75 mg/mouse) groups compared to vehicle control. Micro-immunotherapy medicine exerted the highest effect at the lowest dose tested. Micro-immunotherapy medicine resolved the local and systemic inflammation, even if partially, in a model of pollen-induced, IgE-mediated inflammation.