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

The concept of treatment beliefs in children and adolescents with chronic health conditions: a scoping review

Children and adolescents with chronic health conditions are faced with ongoing challenges, making self-regulation crucial. As children grow up, they gradually develop differentiated beliefs about illness and treatment. While research indicates treatment beliefs as relevant factor on outcomes like adherence, the specific contents and dimensions of children's and adolescents' treatment beliefs remained unclear. This scoping review therefore aimed at the identification of treatment beliefs dimensions in children and adolescents with chronic health conditions, the underlying theoretical frameworks, and methodological operationalisation. Published literature was examined by applying systematic searches in electronic databases (Medline, PsycINFO, CINAHL) and comprehensive selection criteria, resulting in 49 included studies. The predominant treatment beliefs dimensions were necessity, concerns, perceived benefits and costs/barriers, and expectations. The latter can be differentiated into outcome, social, process, and structural expectations, and expectations of one's own role in the treatment process. In addition, dimensions that cover emotions and reasons for treatment were identified. The results are related to the methods and theoretical models applied, which were often adapted from adult research. However, additional and possibly more child-specific dimensions such as social expectations and emotions were found. This scoping review indicates several research gaps and discusses practical implications.

Guardian's knowledge and attitude towards inhaled corticosteroids aerosol therapy and medication compliance of children with wheezing diseases

BACKGROUND

Glucocorticoids are widely used in inhalation aerosol therapy for wheezing diseases. This study aims to explore guardians' knowledge and attitude towards inhaled corticosteroids (ICS) aerosol therapy and the medication compliance of children with wheezing diseases in China.

METHODS

This cross-sectional study enrolled guardians of children with wheezing diseases at the First Hospital Affiliated to Shaoyang College between October 2022 and February 2023. A self-administered questionnaire was developed to collect demographic information of the participants and evaluate their knowledge and attitude towards ICS aerosol therapy. The 8-item Morisky Medication Adherence Scale was used to assess the medication compliance of children.

RESULTS

A total of 506 valid questionnaires were collected. 260 (51.38%) participants were guardians of a ≤ 3-year-old child and 327 (64.62%) were children's mothers. The knowledge, attitude, and medication compliance scores of all participants were 12.61 ± 5.78, 20.95 ± 2.37, and 4.69 ± 2.18, respectively. Multivariate logistic regression showed that knowledge scores [OR = 1.053, 95% CI (confidence interval): 1.017-1.090, P = 0.003], attitude scores (OR = 1.121, 95% CI: 1.030-1.219, P = 0.008), guardians of children aged 4-6 years (OR = 0.385, 95% CI: 0.242-0.612, P < 0.001), and grandparents of children (OR = 2.633, 95% CI: 1.104-6.275, P = 0.029) were independently associated with children's medication compliance.

CONCLUSIONS

In conclusion, guardians of children with wheezing diseases in China had insufficient knowledge, unsatisfactory attitude, and poor medication compliance towards ICS aerosol therapy.

TRIAL REGISTRATION

Retrospectively registered.

Intervention for a correct medication list and medication use in older adults: a non-randomised feasibility study among inpatients and residents during care transitions

BACKGROUND

Medication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient's medication use at home.

AIM

In preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions.

METHOD

Participants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed.

RESULTS

Of 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores.

CONCLUSION

Based on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

Preschool children's asthma medication: parental knowledge, attitudes, practices, and adherence

Introduction: As parents or legal guardians primarily care for children with asthma, understanding their knowledge, attitudes, and practices (KAP) barriers to treatment and medication adherence is of essential importance. This study aimed to analyze the KAP toward asthma medication and adherence among preschool-aged asthmatic children's parents and explore the factors influencing adherence. Methods: This cross-sectional study was conducted between February 2023 and April 2023. Parents of preschool children with asthma were asked to complete the questionnaire containing knowledge, attitude, practice dimensions, and demographic characteristics. The Morisky Medication Adherence Scale (MMAS) was used to investigate adherence. Results: A total of 632 valid questionnaires (154 male and 478 female) were included. Parents showed moderate knowledge (9.49 ± 2.86, 63.27%, possible range: 0-15) and moderate attitudes (26.18 ± 2.51, 74.80%, possible range: 7-35) towards asthma medication, while their practices (27.46 ± 5.26, 91.53%, possible range: 6-30) were proactive; however, medication adherence was low (4.84 ± 1.78, total score: 8). The attitude scores (OR = 1.10, 95% CI: 1.01-1.19, P=0.020), practice scores (OR = 1.16, 95%CI: 1.12-1.21, p < 0.001), and smoking (OR = 1.64, 95%CI: 1.14-2.37, p = 0.008) were associated with medication adherence. Discussion: Preschool-aged asthmatic children's parents showed moderate knowledge, attitudes, and proactive practice toward asthma medication. Continuous training and education programs should be provided for parents to improve asthma medication management in preschool children.

Parents' Beliefs about Medicines and Their Influence on Inhaled Corticosteroid Adherence in Children with Asthma

The most widespread chronic condition observed amid children globally is asthma. Only half of children with asthma adhere to their prescribed inhaled corticosteroids (ICS) therapy. Parents' emotions and perspectives regarding asthma have an impact on inhalation corticosteroid adherence. The participants in this study were 148 parents of children with asthma, with the aim to redintegrate their beliefs about medicines in general and specifically of ICS and the impact on ICS adherence in children with asthma. Children were mostly male (66.9%), older than five years (58.8%), parents were female, mean age 38, employed, and with a history of consumption of some form of corticosteroids. Parents' answers show that 50% of them disagreed with the statement that medicines are addictive, and 90% agree that medicine helps many to live better. A percentage of 77.7% of parents acknowledge that their child's health relies on inhaled corticosteroids (ICS), and 86.5% of parents agree that these medications safeguard their child from worsening health. Most of the parents (93.2%) adhere to the guidelines and instructions of the doctor. In summary, parents who hold the belief that medicines are neither overused nor harmful tend to exhibit a higher adherence. Furthermore, those with elevated adherence levels express lower levels of concern regarding the use of inhaled corticosteroids (ICS) in their children's asthma therapy.

Attention-Deficit Hyperactivity Disorder Symptoms, Underperception of Respiratory Compromise, and Illness Representations in Black and Latino Children With Asthma

OBJECTIVE

This study examined the associations between attention-deficit/hyperactivity disorder (ADHD) symptoms, underperception of respiratory compromise, and illness representations in Black and Latino children with asthma. We hypothesized that increased child-reported ADHD symptoms, as well as parent reports for their child, would be associated with underperception of respiratory compromise, and maladaptive asthma beliefs.

METHODS

Two hundred ninety-six parent-child dyads were recruited from pediatric asthma and primary care clinics in the Bronx. Participants completed demographic questionnaires, the Conners-3 ADHD Index to measure ADHD symptoms, and the Asthma Illness Representation Scale to assess asthma beliefs. Perception of respiratory compromise was assessed by programmable electronic peak flow monitors that measured the child's subjective estimates of peak expiratory flow (PEF) and actual PEF, with underperception as the primary measure.

RESULTS

Child-reported ADHD symptoms were associated with greater underperception (β = .117, p = .049) of respiratory compromise. Parent-reported ADHD symptoms were associated with greater underperception (β = .129, p = .028) of respiratory compromise. Child-reported ADHD symptoms (β = -.188, p < .001) were associated with more maladaptive asthma beliefs, F(1, 341) = 13.135. Parent-reported ADHD symptoms (β = -.203, p ≤ .001) were associated with more maladaptive asthma beliefs, F(1, 341) = 15.644.

CONCLUSIONS

ADHD symptoms were associated with a greater underperception of respiratory compromise and more maladaptive asthma beliefs. Deficits of attentional processes and/or hyperactivity levels might be contributing factors. We emphasize the need for psychoeducation and interventions that improve perception and health beliefs in children with comorbid ADHD and asthma.

Non-adherence, medication beliefs and symptom burden among patients receiving hemodialysis -a cross-sectional study

BACKGROUND

Non-adherence to medication is a common and complex issue faced by individuals undergoing hemodialysis (HD). However, more knowledge is needed about modifiable factors influence on non-adherence. This study investigated the prevalence of non-adherence, medication beliefs and symptom burden and severity among patients receiving HD in Denmark. Associations between non-adherence, medications beliefs and symptom burden and severity were also explored.

METHOD

A cross-sectional questionnaire-based multisite study, including 385 participants. We involved patient research consultants in the study design process and the following instruments were included: Medication Adherence Report Scale, Beliefs about Medication Questionnaire and Dialysis Symptom Index. Logistic regression analysis was performed.

RESULTS

The prevalence of non-adherence was 32% (95% CI 27-37%) using a 23-point-cut-off. Just over one third reported being concerned about medication One third also believed physicians to overprescribe medication, which was associated with 18% increased odds of non-adherence. Symptom burden and severity were high, with the most common symptoms being tiredness/ lack of energy, itching, dry mouth, trouble sleeping and difficulties concentrating. A high symptom burden and/or symptom severity score was associated with an increased odd of non-adherence.

CONCLUSION

The study found significant associations between non-adherence and, beliefs about overuse, symptom burden and symptom severity. Our results suggest health care professionals (HCP) should prioritize discussion about medication adherence with patients with focus on addressing patient-HCP relationship, and patients' symptom experience. Future research is recommended to explore the effects of systematically using validated adherence measures in clinical practice on medication adherence, patient-HCP communication and trust. Additionally, studies are warranted to further investigate the relationship between symptom experience and adherence in this population.

TRIAL REGISTRATION

NCT03897231.

Encouraging adherence in adolescents with asthma using financial incentives: An RCT

BACKGROUND

Medication adherence in adolescents remains a significant management challenge and innovative strategies are needed to improve medication adherence. Financial incentives have been used to improve outcomes for health behaviors among adults, but have not been well-studied among adolescents. The objective of this study was to test if a modest financial incentive improved medication adherence in adolescents with asthma compared with a control group.

METHODS

Participants were randomized to either control (electronic medication monitoring [EMM] with App reminders/feedback for 4 months) or intervention (EMM + $1 per day for perfect medication adherence for 3 months [maximum $84] followed by 1 month of EMM only). A repeated measures mixed model, with a first order autoregressive correlation structure between errors, was used to test the null hypothesis for an interaction of treatment group and week.

RESULTS

Fifty-two participants were enrolled, and 48 completed primary analysis. Mean adherence rates declined in both groups over time, and there was no significant difference in the change in adherence rates between the groups (F-statistic = 0.72, ndf = 15, ddf = 625, p = 0.76). Adherence rates (during the 12 weeks when incentives were given) declined from 80% to 64% in the control group, and from 90% to 58% in the incentive group. There was no significant change in the slope of decline in the incentives group in the month following payment discontinuation.

CONCLUSION

A modest financial incentive did not lead to significantly different medication adherence rates in adolescents with asthma who were receiving a monitoring and reminder intervention. Further study is needed to determine viable interventions to optimize medication use in this group.

Characteristics and Treatment Outcomes of Transition among Patients with Inflammatory Bowel Disease

PURPOSE

This study aimed to assess disease characteristics and outcomes of transition in patient care among adolescent patients with inflammatory bowel disease (IBD).

MATERIALS AND METHODS

Data from patients younger than 18 years who were diagnosed with IBD (Crohn's disease, ulcerative colitis, or intestinal Behçet's disease) were investigated. We categorized the patients into two groups: transition IBD group (Group A, diagnosed in pediatric care followed by transfer to/attendance in adult IBD care) and non-transition group (Group B, diagnosed and followed up in pediatric care or adult IBD care without transfer).

RESULTS

Data from a total of 242 patients [Group A (n=29, 12.0%), Group B (n=213, 88.0%)] were analyzed. A significantly higher number of patients was diagnosed at an earlier age in Group A than in Group B (p<0.001). Group A patients had more severe disease in terms of number of disease flare ups (p=0.011) and frequency of bowel-related complications (p<0.001). Multiple linear regression analysis showed that Group B patients had more medical non-compliance than Group A patients (β=2.31, p=0.018). After transition, IBD-related admission frequency, emergency admission frequency, disease flare frequency, and medical non-compliance were significantly improved.

CONCLUSION

The transition IBD group had more severe disease. Medical non-compliance was lower in the transition IBD group. Clinical outcomes improved after transition.

Measuring adherence to inhaled control medication in patients with asthma: Comparison among an asthma app, patient self-report and physician assessment

BACKGROUND

Previous studies have demonstrated the feasibility of using an asthma app to support medication management and adherence but failed to compare with other measures currently used in clinical practice. However, in a clinical setting, any additional adherence measurement must be evaluated in the context of both the patient and physician perspectives so that it can also help improve the process of shared decision making. Thus, we aimed to compare different measures of adherence to asthma control inhalers in clinical practice, namely through an app, patient self-report and physician assessment.

METHODS

This study is a secondary analysis of three prospective multicentre observational studies with patients (≥13 years old) with persistent asthma recruited from 61 primary and secondary care centres in Portugal. Patients were invited to use the InspirerMundi app and register their inhaled medication. Adherence was measured by the app as the number of doses taken divided by the number of doses scheduled each day and two time points were considered for analysis: 1-week and 1-month. At baseline, patients and physicians independently assessed adherence to asthma control inhalers during the previous week using a Visual Analogue Scale (VAS 0-100).

RESULTS

A total of 193 patients (72% female; median [P25-P75] age 28 [19-41] years old) were included in the analysis. Adherence measured by the app was lower (1 week: 31 [0-71]%; 1 month: 18 [0-48]%) than patient self-report (80 [60-95]) and physician assessment (82 [51-94]) (p < 0.001). A negligible non-significant correlation was found between the app and subjective measurements (ρ 0.118-0.156, p > 0.05). There was a moderate correlation between patient self-report and physician assessment (ρ = 0.596, p < 0.001).

CONCLUSIONS

Adherence measured by the app was lower than that reported by the patient or the physician. This was expected as objective measurements are commonly lower than subjective evaluations, which tend to overestimate adherence. Nevertheless, the low adherence measured by the app may also be influenced by the use of the app itself and this needs to be considered in future studies.

Treatment Beliefs of Children and Adolescents With Chronic Diseases: Development of the Rehabilitation Treatment Beliefs Questionnaire for Children and Adolescents

OBJECTIVE

Rehabilitation is an important component in the health care of children and adolescents with chronic diseases and aims at supporting patients' self-regulation for dealing with the disease. Patients' beliefs about illness and treatment are core elements in the self-regulation process. While questionnaires measuring illness beliefs for children and adolescents exist, questionnaires about their rehabilitation-related treatment beliefs are lacking. We therefore developed a questionnaire to assess the rehabilitation-related treatment beliefs of children and adolescents with chronic diseases (Rehabilitation Treatment Beliefs Questionnaire, RTBQ) and tested its psychometric properties.

METHODS

Ahead of their rehabilitation, children and adolescents, aged 12-17 years, answered 129 items, which were developed based on previous qualitative findings exploring children and adolescents' rehabilitation-related treatment beliefs. Psychometric testing included item analyses, exploratory factor analysis, internal consistency and bivariate correlations of the extracted scales, and the discriminatory power and difficulty of the final items.

RESULTS

The sample consisted of 170 participants with a mean age of 14.3 years (SD = 1.6); 53.5% were female. After item analyses, 47 items remained for the exploratory factor analysis which revealed 22 items allocated to 4 scales: "expectations of communication and interaction," "expectations of the treatment process," "expectations of treatment success and sustainability," and "expectations of one's own role in the rehabilitation process." The psychometric properties were acceptable to good.

CONCLUSIONS

The RTBQ assesses various dimensions of rehabilitation-related treatment beliefs of children and adolescents with chronic diseases. While first psychometric results are promising, further psychometric testing is needed.

The relationship between medication adherence and illness perception in breast cancer patients with adjuvant endocrine therapy: beliefs about medicines as mediators

PURPOSE

To describe medication adherence, to analyze the relationships among medication adherence, illness perception, and beliefs about medicines, and to determine the mediating effects of beliefs about medicines on the relationship in breast cancer patients with adjuvant endocrine therapy (AET) in China.

METHODS

A cross-sectional study was conducted on 202 breast cancer patients with AET from September 2017 to February 2019 in China. The Medication Adherence Report Scale (MARS-5), the Chinese version of the revised illness perception questionnaire for Breast Cancer (CIPQ-R-BC) and the Beliefs about Medicines Questionnaire (BMQ) were used.

RESULTS

The mean MARS-5 score of our participants was 23.72 (SD = 1.62), and 175 (86.6%) patients were adherent to medications. Moreover, medication adherence was negatively correlated with identity, environmental or immune factors, emotional representations, BMQ-specific concerns, BMQ-general overuse, and BMQ-general harm, as well as being positively correlated with coherence and the total BMQ scores. Furthermore, beliefs in the overuse about medicines functioned as mediators for the influencing effects of coherence and emotional representations on medication adherence.

CONCLUSION

Illness perception not only directly affected medication adherence, but also indirectly affected medication adherence through the beliefs about medicines. Necessary interventions that target beliefs in the overuse about medicines in breast cancer patients with AET with low levels of coherence or high levels of emotional representations could be provided to improve the level of their medication adherence.

Characteristics of inpatients with atopic asthma in a tertiary center: Do age and gender have an influence?

Background: Several studies have demonstrated gender influence on asthma prevalence, being higher among males during early childhood. Little is known about the impact of gender and age on asthma exacerbation characteristics in pediatrics. This study aimed to determine the differences in acute asthma between males and females in three different age groups regarding perinatal characteristics of asthmatic patients, comorbidities, medication adherence, level of blood eosinophils, and pattern of hospitalization.Methods: The medical records of 130 pediatric patients with asthma, who presented to the emergency department at Jordan University hospital with asthma exacerbations, were retrospectively reviewed. Demographic information and clinical characteristics were collected.Results: The mean age of patients was 10.7±4.7 years. The age at diagnosis and gestational age were significantly higher in older children. Furthermore, younger children were significantly more likely to experience winter exacerbations and more emergency presentations. Male patients were considerably younger than their female counterparts and were diagnosed younger. In addition, male patients were more likely to have eosinophil levels higher than 3% than female patients.Conclusion: Gender plays a role in the development and outcome of asthma exacerbations at different ages of pediatrics. A better understanding of gender-based and age-based differences in asthma dictates a personalized approach to treatment.

[Therapeutic adherence among asthma patients: Variations according to age groups. How can it be improved? The potential contributions of new technologies]

While asthma patients' treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.

Association of depression and antidepressant therapy with antiretroviral therapy adherence and health-related quality of life in men who have sex with men

UNAIDS’ HIV treatment targets require that 90% of people living with HIV/AIDS (PLWHA) receiving antiretroviral treatment (ART) achieve viral suppression and 90% of people with viral suppression have good health-related quality of life (HRQOL). This study aimed to examine the association of depression and antidepressant therapy with ART adherence and HRQOL in HIV-infected men who have sex with men (MSM). From 2018 through 2020, HIV-infected MSMs were consecutively recruited (N = 565) for the evaluation of ART adherence and HRQOL at Taipei City Hospital HIV clinics. Non-adherence to ART was defined as a Medication Adherence Report Scale score of < 23. HRQOL in PLWHHA was evaluated using WHOQOL-BREF, Taiwan version. Overall, 14.0% had depression and 12.4% exhibited non-adherence to ART. The nonadherence proportion was 21.8% and 10.5% in depressed and nondepressed HIV-infected MSM, respectively. After adjusting for other covariates, depression was associated with a higher risk of nonadherence to ART (adjusted odds ratio = 2.02; 95% confidence interval: 1.02–4.00). Physical, psychological, social, and environmental HRQOL were significantly negatively associated with depression. Considering antidepressant therapy, ART nonadherence was significantly associated with depression without antidepressant therapy but not with antidepressant therapy. The depressed HIV-infected MSM without antidepressant therapy had worse psychological, social, and environmental HRQOL than those with antidepressant therapy. Our study suggests that depression is associated with poor ART adherence and HRQOL, particularly in those without antidepressant therapy. Adequate diagnosis and treatment of depression should be provided for PLWHA to improve their ART adherence and HRQOL.

Psychometric evaluation of the medication adherence report scale in caregivers of low-income, urban, African American children with poorly controlled asthma

OBJECTIVE

Accurately assessing asthma medication usage among low-income, urban, African American children is essential to reduce asthma health disparities. The purpose of this study was to examine the factor structure of the five-item Medication Adherence Report Scale (MARS), in a sample of caregivers of low-income, urban, African American youth with poorly controlled asthma.

METHOD

Using baseline data from a randomized clinical trial evaluating the efficacy of an environmental control educational intervention, confirmatory factor analysis (CFA) was conducted to ascertain the MARS factor structure. Construct validity was assessed using a regression model inclusive of caregiver-reported medication adherence, Asthma Medication Ratio (AMR), asthma control, and caregiver perception of asthma control as predictors of the MARS.

RESULTS

Caregivers were female (97%) and 27.4% had an annual income under $10,000. The mean MARS score was 21.88 ± 3.33 out of a possible range of 5-25, representing high adherence. Confirmatory factor analysis indicated that a five-item one-factor model marginally fit the data based on the fit indices: χ² (5) = 31.71, p < 0.001; RMSEA ≤ 0.161; CFI = 0.986; TLI = 0.971; and WRMR = 0.979. The MARS was associated with another caregiver-reported measure of medication adherence but not associated with AMR, asthma control, or caregiver perception of asthma control.

CONCLUSIONS

The MARS demonstrated marginal fit in CFA and may not be clinically indicated in light of the lack of associations with objective measures of asthma medication adherence and asthma control.

The lived experience of adherence to asthma medication in young adults (18-34 years)

BACKGROUND

Adherence to asthma medications is commonly poor and is the primary cause for anticipated worsening health outcomes for patients with asthma. Worldwide, qualitative investigations that examine the adherence of young adults (18-34 years) to their asthma medication are limited.

METHOD

This study used a phenomenological research approach to explicate the experience of asthma medication adherence as described by young adults. Data were collected using semi-structured in-depth video interviews conducted with participants aged between 18 and 34 years to elicit their lived experience with adherence to asthma medication. Data from the interviews were transcribed and analyzed using the Edward and Welch (1) extension of Colaizzi's approach to phenomenology.

RESULTS

Results yielded four main themes related to the phenomenon of adherence that emerged from the analysis. The themes were: Having a plan; Having knowledge about your medication and asthma triggers; Being responsible with asthma medication; and Health belief.

CONCLUSION

According to the findings, for young people adhering to asthma medication is a process that depends on four vital aspects: (A) plan, (B) knowledge, (C) responsibility, and (D) belief. If young adults with asthma received individualized written asthma plans and have adequate knowledge about this plan, developing the correct health belief is likely to result. Hence, this can lead to a greater responsibility to manage their asthma to the recommended adherence level.

A Smartphone App to Support Adherence to Inhaled Corticosteroids in Young Adults With Asthma: Multi-Methods Feasibility Study

Background

Young adults with asthma often report low adherence to inhaled corticosteroids (ICS), leading to uncontrolled symptoms and poor disease outcomes. Technology-enabled digital supports such as mobile health (mHealth) asthma smartphone apps have the potential to support adherence to ICS and asthma self-management. There is a need for feasibility studies to determine the usability, acceptability, and feasibility of these interventions. In addition, it is essential to determine the feasibility of recruiting and retaining young adults to plan future efficacy and effectiveness trials and therefore, establish evidence-based asthma apps.

Objective

This study aimed to determine (1) the feasibility of recruiting and retaining young adults to a trial and (2) the usability, acceptability, and feasibility of using the AsthmaMD app to support adherence to ICS in a population of young adults living with asthma.

Methods

A multi-methods feasibility study was conducted. Young adults aged 18-30 years with asthma and current prescription for ICS were eligible and invited to take part through a university circular email, social media, and general practice sites. Participation involved completing a baseline self-report questionnaire, downloading and using the AsthmaMD app for 2 weeks, and completing the follow-up assessment, including self-report and open-ended questions about participants’ experience of using the app. Primary outcomes included participant recruitment and retention and the usability, acceptability, and feasibility of using AsthmaMD. Quantitative self-report data were analyzed using descriptive statistics, and qualitative open-ended data were analyzed using inductive reflexive thematic analysis.

Results

A total of 122 young adults (females, n=101, 82.8%) with a mean age of 24.4 (SD 3.8) years were recruited and they completed baseline measures. Of the 122 young adults, 59 (48.4%) completed the study. The AsthmaMD app received a mean score of 63.1/100 (SD 20.1) on the System Usability Scale (ie, a standardized measure of usability for technology-based apps), and an overall user satisfaction score of 5.8/10 (SD 2.2). Of the 59 participants who completed the study, 49 (83%) participants used the app ≥1 day per week. Two main themes were identified in the qualitative analysis of user experiences: (1) learning how to use the app to suit the individual and (2) benefits and relevance of using the app.

Conclusions

The findings from this study indicate that it is feasible to recruit and retain young adults to examine efficacy and effectiveness in a future trial and that young adults living with asthma may find AsthmaMD to be usable, acceptable, and feasible to support adherence to ICS. Our findings also identified opportunities to further optimize the usability of AsthmaMD and similar apps. Based on our findings, we recommend providing more accessible information on how to use the app and replacing medical terminology with simplified language within the app to improve usability.

Trial Registration

ISRCTN Registry ISRCTN11295269; https://www.isrctn.com/ISRCTN11295269

Medication Adherence in Patients With Severe Asthma Prescribed Oral Corticosteroids in the U-BIOPRED Cohort

BACKGROUND

Although estimates of suboptimal adherence to oral corticosteroids in asthma range from 30% to 50%, no ideal method for measurement exists; the impact of poor adherence in severe asthma is likely to be particularly high.

RESEARCH QUESTIONS

What is the prevalence of suboptimal adherence detected by self-reporting and direct measures? Is suboptimal adherence associated with disease activity?

STUDY DESIGN AND METHODS

Data were included from individuals with severe asthma taking part in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes) study and prescribed daily oral corticosteroids. Participants completed the Medication Adherence Report Scale, a five-item questionnaire used to grade adherence on a scale from 1 to 5, and provided a urine sample for analysis of prednisolone and metabolites by liquid chromatography-mass spectrometry.

RESULTS

Data from 166 participants were included in this study: mean (SD) age, 54.2 (± 11.9) years; FEV₁, 65.1% (± 20.5%) predicted; female, 58%; 37% completing the Medication Adherence Report Scale reported suboptimal adherence; and 43% with urinary corticosteroid data did not have detectable prednisolone or metabolites in their urine. Good adherence by both methods was detected in 49 of the 142 (35%) of participants in whom both methods were performed; adherence detection did not match between methods in 53%. Self-reported high adherers had better asthma control and quality of life, whereas directly measured high adherers had lower blood eosinophil levels.

INTERPRETATION

Low adherence is a common problem in severe asthma, whether measured directly or self-reported. We report poor agreement between the two methods, suggesting some disassociation between self-assessment of medication adherence and regular oral corticosteroid use, which suggests that each approach may provide complementary information in clinical practice.

Effect of pharmacists' interventions on health outcomes of children with asthma: A systematic review

METHODS

A literature search was performed in January 23, 2018 at the Embase, LILACS, OpenThesis, PubMed, Cochrane Library, and Web of Science databases through January 23, 2018, using keywords related to "asthma," "pharmacist," and "children." This systematic review followed the methodologic standards recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included intervention studies on the effect of pharmacists' interventions on pediatric patients with asthma, performed in hospital or ambulatory care settings, with presenting process and outcome indicators as a result of pharmacists' interventions. The methodologic quality of the included studies was assessed independently by 2 researchers. The Cohen kappa index was used to measure the degree of agreement between the 2 investigators.

RESULTS

The search yielded 3671 records, of which 5 were included in this review. Most of these studies were conducted in the United States (n = 2) and in outpatient clinics (n = 4). All studies described components of pharmacists' interventions. The most reported category concerning pharmacists' work process was the initial assessment of patients' conditions, with the assessment of outcomes (at baseline and follow-up) as the only category present in all studies. The most assessed outcomes at baseline were asthma control, emergency department visits, medication use and technique, and adherence to asthma therapy. At follow-up, emergency department visits were the most evaluated outcome (n = 2), and no study assessed economic outcomes. The average consultation time ranged from 20 to 45 minutes, and the number of encounters ranged from 2 to 3.

CONCLUSION

This study highlighted the limited number of studies, most with low quality, on the impact of the pharmacist on pediatric asthma. The most assessed outcome was the number of emergency department visits, with positive results after interventions. Heterogeneity regarding assessed outcomes and work processes was noted, which limited comparison of the results and interventions.

Development and validation of a self-report measure of practical barriers to medication adherence - the Medication Practical barriers to Adherence Questionnaire (MPRAQ)

AIM

This study reports the development and validation of a new self-report measure (MPRAQ) that assesses practical barriers to medication adherence.

METHODS

MPRAQ comprises fifteen statements describing practical barriers. Responses are scored on a 5-point Likert scale; higher scores indicate more practical barriers. Initial face validity was evaluated by cognitive testing with patients from a diabetes support group. Following refinement, internal reliability and construct validity were assessed in two samples: patients recruited via Amazon mTurk and the Nivel Dutch Healthcare Consumer Panel (COPA). Respondents completed the Beliefs about Medicines Questionnaire (BMQ - general and specific), and Medication Adherence Report Scale (MARS-5). The mTurk sample also completed the Perceived Sensitivity to Medicines questionnaire (PSM), and repeated MPRAQ two weeks later to assess test-retest reliability.

RESULTS

Face validity was evaluated in 15 patients (46% female; mean (SD) age 64(12) years). A total of 184 mTurk participants completed the questionnaire (in English) and 334 in COPA (in Dutch). Internal reliability was acceptable (mTurk α=0.89; COPA α=0.94). Construct validity was confirmed, with significant correlation between MPRAQ and BMQ-Specific Concerns (mTurk r=0.546, p<0.0001; COPA r=0.370, p<0.0001); BMQ-General Harm (mTurk r=0.504, p<0.0001; COPA r=0.219, p<0.0001); BMQ-General Overuse (mTurk, r=0.324, p<0.0001; COPA r=0.109, p=0.047), and PSM (mTurk only, r=0.463, p<0.0001), and a negative correlation with MARS-5 (mTurk r=-0.450, p<0.0001; COPA r=-0.260, p<0.0001). MPRAQ did not correlate with BMQ-Specific Necessity or BMQ-General Benefit. Correlation between MPRAQ baseline and 2-week follow-up scores confirmed test-retest reliability (r=0.745, p<0.0001; n=52).

CONCLUSION

MPRAQ is a reliable and valid self-report measure of practical adherence barriers.

EAACI Guidelines on the effective transition of adolescents and young adults with allergy and asthma

Adolescent and young adult (AYA) patients need additional support, while they experience the challenges associated with their age. They need specific training to learn the knowledge and skills required to confidently self-manage their allergies and/or asthma. Transitional care is a complex process, which should address the psychological, medical, educational and vocational needs of AYA in the developmentally appropriate way. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline to provide evidence-based recommendations for healthcare professionals to support the transitional care of AYA with allergy and/or asthma. This guideline was developed by a multidisciplinary working panel of experts and patient representatives based on two recent systematic reviews. It sets out a series of general recommendations on operating a clinical service for AYA, which include the following: (a) starting transition early (11-13 years), (b) using a structured, multidisciplinary approach, (c) ensuring AYA fully understand their condition and have resources they can access, (d) active monitoring of adherence and (e) discussing any implications for further education and work. Specific allergy and asthma transition recommendations include (a) simplifying medication regimes and using reminders; (b) focusing on areas where AYA are not confident and involving peers in training AYA patients; (c) identifying and managing psychological and socio-economic issues impacting disease control and quality of life; (d) enrolling the family in assisting AYA to undertake self-management; and (e) encouraging AYA to let their friends know about their allergies and asthma. These recommendations may need to be adapted to fit into national healthcare systems.

Barriers to medication adherence in the emergency department: A cross-sectional study

BACKGROUND

Medication nonadherence is a common problem that leads to increased healthcare utilization. It is unclear how patient insight and attitude towards their medications affect adherence in the ED. Furthermore, it is unclear how perceived medication importance differs between patients and ED physicians.

METHODS

We conducted a cross sectional study of adult patients presenting to 2 academic emergency departments from April 2015 to October 2016. Demographic data were collected and questions were asked regarding medication knowledge, perceived importance, and adherence. We also compared perceived importance of medications between patients and two physician raters. Inter-rater agreement was reported as raw percentages, and categorical data were compared using chi-squared analysis.

RESULTS

We identified 1268 patients, representing 4634 individual medications. We identified a significant association between knowledge of medications and perceived importance (p < .05). Secondarily, importance level was highly associated with medication adherence (p < .05). When ranking those medications that were considered "least" and "most" important among each patient's med list, our two physicians agreed with patients only 34.1% and 37% of the time respectively, as opposed to 62% and 62.8% agreement between each other.

CONCLUSIONS

These data suggest that there is a difference in perceived medication importance between ED physicians and ED patients. Knowledge of a medication's purpose is significantly associated with perceived importance, while this importance appears to be significantly associated with compliance. These results suggest that concerted efforts by ED physicians and staff to educate patients on the utility and importance of their medications may improve adherence.

Understanding the challenges faced by adolescents and young adults with allergic conditions: A systematic review

BACKGROUND

Adolescence represents a vulnerable time for individuals with asthma and allergic conditions. They suffer an unexpected degree of morbidity. This systematic review aimed to understand the challenges faced by adolescents and young adults with these conditions.

METHODS

A systematic literature search was undertaken across eight databases. References were checked by two reviewers for inclusion. Study data were extracted, and their quality was assessed in duplicate. A narrative meta-synthesis was undertaken.

RESULTS

A total of 108 papers describing 106 studies were retrieved, most focused on asthma. Five themes were identified across studies: (a) Health-related quality of life-impairment was associated with poor disease control, psychosocial issues, adolescent-onset allergic disease and female sex; (b) Psychological factors-asthma and food allergy were associated with anxiety and depression, atopic dermatitis was associated with suicidal ideation, and that parental emotional support may be protective; (c) Adherence-suboptimal adherence was associated with older age, barriers to medication usage, poor symptom perception and failure to take responsibility, and positive factors were routines, simpler treatment regimes, better knowledge and perceptions about medications; (d) Self-management-facilitated by education, knowledge and a positive attitude; and (e) Supportive relationships-families could modify barriers to adherence and foster positive views about self-management, adolescents suggested that their peers should be more involved in supporting them, and adolescents also wished to have support from nonjudgemental healthcare professionals.

CONCLUSIONS

We have some understanding of the challenges faced by adolescents with asthma, less so for other allergic conditions. This knowledge will be used to support guidelines for managing adolescents.

Inhaled corticosteroid beliefs, complementary and alternative medicine in children presenting to the emergency department for asthma

OBJECTIVE

Negative beliefs about inhaled corticosteroids (ICS) and endorsement of complementary and alternative medicine (CAM) have been associated with medication non-adherence and uncontrolled asthma. The association of CAM and negative health beliefs is not described in children in acute care settings. Our study objective is to determine the relationship between negative ICS beliefs, CAM use and poorly controlled asthma among a predominantly Latino population in an acute care setting.

METHODS

The study was conducted in the pediatric emergency department of a children's hospital. During an ED asthma encounter, validated questionnaires surveyed parents about negative ICS beliefs, CAM use, and asthma health and control. We compared asthma health reports between parents who did or did not endorse negative ICS beliefs or CAM use, by chi-squared test (or a Fisher's exact test where appropriate).

RESULTS

Parents of 174 children identified mostly as Latino with Medicaid insurance and high asthma morbidity. CAM endorsement and negative ICS beliefs were both associated with increased use of lifetime glucocorticoid (p = 0.03 and p=0.01 respectively). While CAM endorsement was associated with less hospitalizations (p = 0.04) and parental report of asthma "getting better" (p = 0.01), CAM users reported trouble with paying for rent or food (p = 0.02). Negative ICS beliefs and CAM endorsement were not associated with medication adherence.

CONCLUSIONS

Negative ICS beliefs are associated with higher number of oral glucocorticoid courses. The association between CAM endorsement and asthma control is varied, but mostly in favor of improved control. Financial difficulties may make CAM use more likely.

Asthma and subsequent school performance at age 15-16 years: A Swedish population-based sibling control study

Asthma may negatively affect children’s school performance, such as grades and exam results. Results from previous studies have shown varying results and may have suffered from confounding and other biases. We used a Swedish population-based cohort of 570,595 children with data on asthma (including severity and control) in Grades 7–8 and 9, school performance from Grade 9 (grade point sum, non-eligibility for upper secondary school and national test results) and measured confounders from national registers. We used sibling comparisons to account for unmeasured familial factors. Children with asthma and severe asthma performed slightly better in school than children without asthma when adjusting for measured confounders, but the associations were attenuated in sibling comparisons. In contrast, children with uncontrolled asthma performed slightly worse (e.g. Grade 9: β_adj = −9.9; 95% CI −12.8 to −7.0; Cohen’s d = 0.16). This association remained for uncontrolled asthma in Grade 9 in sibling comparisons (Grade 9: β = −7.7 points; 95% CI −12.6 to −2.6; Cohen’s d = 0.12), but not for Grades 7–8. The attenuation of estimates when controlling for familial factors using sibling comparisons suggests that the differences were due to familial factors, rather than being causal. The remaining associations in sibling comparisons between uncontrolled asthma in Grade 9 and school performance are consistent with a causal association.

Methamphetamine Use Associated with Non-adherence to Antiretroviral Treatment in Men Who Have Sex with Men

Methamphetamine is a prevalent recreational drug among men who have sex with men (MSM) living with HIV and could cause the cognitive impairment and memory loss. However, studies on the association between methamphetamine use and adherence to antiretroviral treatment (ART) are limited and had inconsistent findings. This study aimed to determine the impact of methamphetamine use on adherence to ART among MSM living with HIV. From December 2018 to October 2019, MSM living with HIV were recruited (N = 351) and non-adherence to ART was defined as a Medication Adherence Report Scale score of <23. Overall, 16.0% of the participants reported methamphetamine use in the prior three months and 13.4% of the participants had non-adherence to ART. The proportion of non-adherence to ART among HIV-positive MSM were 28.6% and 10.5% with and without methamphetamine use, respectively. After controlling for demographics, illicit drug use, and co-morbidities, methamphetamine use during the prior three months was associated with a higher risk of non-adherence to ART (adjusted odds ratio = 3.08; 95% confidence intervals: 1.24-7.69). Compared with HIV-positive MSM with non-adherence to ART, HIV-positive MSM with good adherence to ART had a higher CD4 counts and were more likely to achieve an undetectable viral load. Since poor adherence to ART is associated with an increased HIV viral load and the risk of HIV transmission to others, our study suggests that it is imperative to screen HIV-positive patients for methamphetamine use and to provide effective therapy to reduce methamphetamine use and the associated non-adherence to ART.

They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity

Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.

Inhaled corticosteroid-phobia and childhood asthma: Current understanding and management implications

Asthma is the most prevalent chronic disease in children. Inhaled corticosteroids (ICS) is the first-line controller therapy for children with persistent asthma, however, suboptimal compliance to ICS therapy remains as a major obstacle in paediatric asthma management. Steroid-phobia, the fear of side-effects and subsequent aversion of ICS, has been widely reported in parents of asthmatic children. The reported prevalence of steroid-phobia varies widely from 19% to 67% in different populations. The concerns about ICS frequently raised by parents include growth suppression, weight gain, bone weakness, addiction and psychiatric disturbances. Outside of growth suppression, which is statistically significant yet mild in clinical studies, the other concerns are not evidence-based and are misconceptions. Conflicting results have been reported regarding the impact of steroid-phobia on ICS compliance. In contrast, steroid-phobia has consistent and negative effects on asthma control in children. While asthma educational programmes have demonstrable benefits in general paediatric populations, the generalisability of such programmes to steroid-phobic parents remains undetermined. There is a paucity of data on specific educational programmes to clear misconceptions and reduce steroid-phobia. Given the continually raising prevalence of paediatric asthma, high-quality studies are warranted to investigate the prevalence and impact of steroid-phobia, with an ultimate goal of developing effective strategies to tackle steroid-phobia and improve asthma care in children.

Prevalence and predictors of adherence to inhaled corticosteroids in young adults (15-30 years) with asthma: a systematic review and meta-analysis

Objective: Adherence to inhaled corticosteroids (ICS) is an essential part of asthma management throughout the lifespan; however, this may be particularly challenging during the transition into adulthood. This systematic review aimed to determine the prevalence and predictors of adherence to ICS in emerging adulthood.Data sources: MEDLINE, PsycINFO, EMBASE, Scopus, and CINAHL were searched with search terms for asthma, ICS, adherence, young adults, and predictors combined.Study selection: Studies with participants with diagnosed asthma, currently prescribed ICS, a mean age between 15 and 30 years and reporting the prevalence and/or assessing predictor(s) of adherence using quantitative methods were included.Results: Twenty-nine studies were identified for inclusion (K = 29, N = 187 401). A random effect meta-analysis revealed the pooled prevalence of adherence was 28% (95% CI = 20-38%, k = 16) in studies that provided quantitative information on adherence. Adherence was higher in studies with a mean age <18 years (36%; 95% CI = 36-37%, k = 4). Studies using self-report measures provided higher estimates of adherence (35%; 95% CI = 28-42%, k = 10) than studies using pharmacy refill data (20%; 95% CI = 9-38%, k = 6). A narrative review identified personality, illness perceptions, and treatment beliefs as potentially important predictors of adherence.Conclusion: Adherence is sub-optimal during emerging adulthood, particularly after age 18. More reliable and objective measures are needed to precisely characterize adherence. Greater research and practice attention to emerging adulthood are needed to guide self-management support in those living with asthma at this important lifespan stage.Systematic review registration number: CRD42018092401.

Treatment Adherence in Adolescents with Asthma

The burden of asthma is particularly notable in adolescents, and is associated with higher rates of prevalence and mortality compared with younger children. One factor contributing to inadequate asthma control in adolescents is poor treatment adherence, with many pediatric studies reporting mean adherence rates of 50% or lower. Identifying the reasons for poor disease control and adherence is essential in order to help improve patient quality of life. In this review, we explore the driving factors behind non-adherence in adolescents with asthma, consider their consequences and suggest possible solutions to ensure better disease control. We examine the impact of appropriate inhaler choice and good inhaler technique on adherence, as well as discuss the importance of selecting the right medication, including the possible role of as-needed inhaled corticosteroids/long-acting β₂-agonists vs short-acting β₂-agonists, for improving outcomes in patients with mild asthma and poor adherence. Effective patient/healthcare practitioner communication also has a significant role to engage and motivate adolescents to take their medication regularly.

Psychological predictors of adherence to oral hypoglycaemic agents: an application of the ProMAS questionnaire

Objectives: This study aimed to identify psychological predictors of oral hypoglycaemic agent (OHA) adherence and to compare adherence rates between a novel and well-known instrument, i.e. the Probabilistic Medication Adherence Scale (ProMAS) and Medication Adherence Report Scale (MARS-5).Design and main outcome measures: A longitudinal study design was applied with surveys at baseline and 6-month follow-up. At baseline, OHA adherence using the ProMAS and MARS-5, socio-cognitive determinants and demographics were assessed. At follow-up, the ProMAS was applied as outcome measure, on which socio-cognitive determinants and demographics were regressed using linear regression analysis.Results: The baseline and follow-up sample included 304 and 231 participants, respectively. When applying cut-off points of ≥15 for the ProMAS and ≥23 for the MARS-5, 47.4 and 89.5% adhered to their OHAs. Consistent predictors of better adherence comprised a low education, lower severity perceptions, and higher self-efficacy and intention. After correcting for baseline adherence, a low education and higher self-efficacy remained significant adherence predictors.Conclusions: Compared to the MARS-5, ProMAS data was less skewed, similar to objectively collected data, and yielded insights in a broader spectrum of (non)-adherence behaviours. Results stress the need for adherence improving interventions which particularly should target higher educated patients and patients with low self-efficacy, low intention and high severity perceptions.

Questionnaire about the risk of growth suppression of inhaled corticosteroids

BACKGROUND

Inhaled corticosteroids are associated with a risk of growth suppression in children. The aim of the present study was to assess what children with asthma, lay people and paediatricians feel about the risk of growth suppression by inhaled corticosteroids.

METHODS

A questionnaire was completed by seven populations consisting of 9-19 years old children and adolescents with asthma; 9-19 year olds with another chronic illness; healthy 9-19 year olds; parents to children with chronic conditions; parents to healthy schoolchildren; young adults; and paediatricians.

RESULTS

A total of 1216 individuals completed the questionnaire. A total of 867 individuals (74.6%) would not worry about a risk of 1-year growth suppression in the range of 0.5-2 cm (range: 233 (63.3%) in parents to patients in a secondary referral centre to 59 (86.8%) in the group of paediatricians (χ 2 53.3, df 12, p<0.001; γ -223, error 0.042, p<0.001). A total of 745 individuals (64.3%) said that a loss in final height of 0.5-2 cm would not worry them (range: 34 (54.0%) in paediatricians to 119 (76.3%) in parents to healthy children (χ 2 49.5, df 12, p<0.001; γ -0.073, error 0.039, p=0.06).

CONCLUSIONS

Most children with asthma, lay people and paediatricians do not worry about the risk of growth suppression of inhaled corticosteroids in the range up to 2 cm. Paediatricians worry less about the risk of 1-year growth suppression but more about final height suppression than children with asthma and other groups of children and adults. Paediatricians need to address the different concerns of some of their patients on this issue.

Asthma control and quality of life in adolescents: The role of illness perceptions, medication beliefs, and adherence

Objective: Asthma control and quality of life (QoL) are important disease outcomes for asthma patients. Illness perceptions (cognitive and emotional representations of the illness) and medication beliefs have been found to be important determinants of medication adherence, and subsequently disease control and QoL in adults with asthma. In adolescents, this issue needs further elucidation. Therefore, the aim of this study was to explore the relationship between illness perceptions, medication beliefs, medication adherence, disease control, and QoL in adolescents with asthma.Methods: In this cross-sectional study, we used baseline data of adolescents with asthma (age 12-18 years) who participated in the ADolescent Adherence Patient Tool (ADAPT) study. Questionnaires were administrated online, and included sociodemographic variables and validated questionnaires measuring self-reported illness perceptions, medication beliefs, medication adherence, disease control, and QoL.Results: Data of 243 adolescents with asthma were available; age 15.1 ± 2.0 years and 53% females. More than half of these adolescents (62%; n = 151) reported to be non-adherent (Medication Adherence Report Scale ≤23) and 77% (n = 188) had uncontrolled asthma. There was a strong positive correlation between disease control and QoL (r = 0.74). All illness perceptions items were correlated with disease control and QoL, with the strongest correlation between 'identity' (symptom perception) and QoL (r=-0.66). Medication adherence was correlated to medication beliefs (r = 0.38), disease control (r = 0.23), and QoL (r = 0.14), whereas medication beliefs were only associated with adherence.Conclusions: Stimulating positive illness perceptions and medication beliefs might improve adherence, which in turn might lead to improved disease control and better QoL.

Comparing inhaled medications reported by adolescents with persistent asthma and their caregivers

Objectives: To compare concordance (agreement) between teens with persistent asthma and their caregivers on the reported number of inhaled asthma medications used (rescue and controller); examine concordance specific to controller medications; and determine whether concordance over controller medications within caregiver/teen dyads is associated with demographics or clinical outcomes.Methods: We used baseline data from the School-Based Asthma Care for Teens (SB-ACT) trial in urban Rochester, NY. Caregivers and teens (12-16 yrs.) with poorly controlled persistent asthma separately reported the teens' inhaled therapy, and could name up to two rescue and two controller medications. We compared the total number of medications and number of controller medications reported by each dyad member with Cohen's Kappa, and assessed whether concordance over the number of controller medications was associated with demographics, symptoms, or healthcare utilization using chi-square and t-tests.Results: Of 210 dyads (79% public health insurance, 61% Black teens), 132 (63%) were disconcordant in reporting the overall number of inhaled medications. Teens or caregivers from 173 dyads (82%) reported any controller medication; however, a majority (61%) were discordant in the reporting of controller medications. Compared with concordant dyads, fewer caregivers from dyads with controller medication discordance reported education past high school (35% vs. 51%, p = 0.04); no other differences in demographics, symptoms, or healthcare utilization were identified based on controller medication concordance.Conclusions: Most dyads identified different numbers of inhaled medications, with substantial disagreement over controller medications. Working to ensure a basic understanding of treatment plans may promote successful self-management in persistent childhood asthma.

Greater number of perceived barriers to hydroxyurea associated with poorer health-related quality of life in youth with sickle cell disease

BACKGROUND

Despite medical benefits, hydroxyurea adherence in adolescents is often poor. As part of a baseline assessment of 28 youth (10-18 years) parent dyads who participated in a 6-month feasibility trial to improve hydroxyurea adherence, we measured the relationship between greater barriers to adherence and health-related quality of life (HRQL) from youth and parent perspectives.

PROCEDURE

Barriers were measured using the Adolescent and Parent Medication Barriers Scales with nine hydroxyurea items added. Barriers reported by ≥25% of the sample were considered common. Generic and disease-specific HRQL were measured by PedsQL and PedsQL Sickle Cell Disease modules. Data were analyzed using descriptive statistics, Cronbach alpha, Spearman correlation coefficients, and paired t tests.

RESULTS

Fifty-six subjects (28 dyads) participated. Youth reported greater barriers compared with parents (5.0 ± 3.9 and 3.5 ± 3.2; P = 0.03), with >80% of respondents reporting ≥1 barriers. Twelve barriers were reported by ≥25% of adolescents, whereas six were reported by ≥25% of parents. Of these, only two were common to both dyad members. Approximately one-third of youth had generic and disease-specific HRQL scores that fell at or below cutoff scores, suggesting being at risk for impaired HRQL. Greater barriers were inversely associated with poorer generic (parent r = -0.43, P = 0.03; youth r = -0.44, P < 0.001) and disease-specific HRQL (parent r = -0.53, P = 0.005; youth r = -0.53, P < 0.001).

CONCLUSIONS

Hydroxyurea barriers were frequently reported but differed by dyad members' perspective. Greater barriers were associated with poorer generic and disease-specific HRQL. To reduce barriers to hydroxyurea in youth with sickle cell disease, perspectives of both dyad members should be addressed.

The impact of patient-centered medical homes on medication adherence?

Accreditation of providers helps resolve the pervasive information asymmetries in health care markets. However, meeting accreditation standards typically involves flexibility in implementation, leading to heterogeneity in performance. For example, the patient-centered medical home (PCMH) is a leading model for recognizing high-performing primary care practices. Flexibility in PCMH implementation allows for varying degrees of emphasis on processes designed to enhance medication adherence. To assess the impact of the PCMH on adherence, we combine 6 years of detailed patient claims data with a novel dataset containing detailed practice-level PCMH attributes. We study the effects of the number and configuration of adherence-relevant capabilities, using variation in the timing of PCMH adoption to estimate its impact. While PCMH adoption improved overall medication adherence, when combining claims data with the unique recognition data detailing what PCMH capabilities were adopted, we find that these gains are concentrated among patients in practices that adopted more adherence-relevant capabilities. Despite mixed evidence in the literature concerning costs and utilization, our results indicate that PCMH recognition improves medication adherence.

Adherence to asthma treatment in childhood and adolescence - a narrative literature review

OBJECTIVES

We provide a narrative literature review on surveys used to assess the level of medication adherence in children and adolescents with asthma, the attitudes of these patients and their parents toward asthma therapy, and their expectations concerning asthma and available treatment.

METHODS

A PubMed search and manual selection of the retrieved papers was conducted to identify studies using surveys or interviews that addressed one of the three topics of interest.

RESULTS

Adherence to asthma medication varies across age groups and with the type of measurement used. Levels of 49-71% were observed in children and adolescents by objective measurements. Subjective measurements overestimate the level of adherence compared to objective measurements. A considerable percentage of parents expressed fear of side effects of inhaled corticosteroids, although the impact of these concerns on adherence is unclear. Many adolescents and parents adapt inhaled corticosteroids use according to the prevalence of asthma symptoms, by reducing or eliminating controller medication in the absence of symptoms. Pediatric asthma patients and their parents tend to overestimate the level of asthma control, either by underestimating asthma severity or by assuming that a better control is not possible. The knowledge of parents and adolescents concerning asthma management is suboptimal; moreover, insufficient knowledge about inhaled corticosteroids was linked to poor adherence.

CONCLUSION

Medication adherence is crucial for a good control of asthma symptoms. Additional research concerning the triggers of non-adherence is still needed. Educating both the patients and their parents on proper asthma care might improve adherence.

Mixed-methods content and sentiment analysis of adolescents' voice diaries describing daily experiences with asthma and self-management decision-making

BACKGROUND

Accurate symptom assessment remains challenging in teen populations. Little is known of usual symptom/response patterns, and self-reported paper diaries have traditionally low compliance rates. Therefore, we used concurrent digital voice diaries to capture daily asthma experiences.

OBJECTIVE

(a) To qualitatively explore usual symptom patterns and self-management responses and (b) to quantitatively explore relationships between symptom severity and sentiment scores (a marker of emotional response to events).

METHODS

Fourteen minority and nonminority teenagers (age 13-17) with controlled (50%) and uncontrolled asthma used digital recorders to report about their asthma once daily over 14 days. Dairy entries were coded for symptom frequency, severity, type, and self-management responses, while sentiment analysis was used to evaluate the emotional valence of diary entries and to explore whether increased symptom levels correlated with greater negative sentiment.

RESULTS

Symptom frequency and severity recorded in voice diaries were much higher than teens indicated at baseline and were discordant with clinical assessments of asthma control. Of 175 entries, teens had symptoms 69.1% of days (121/175) and severe symptoms on one-third of these. Atypical symptoms (coughing, throat clearing) were reported twice as often as traditional symptoms (wheezing, chest tightness) and often not recognized as asthma, but rather attributed to being "sick" (25.6% of symptom days). Teens frequently minimized symptoms, used rescue and controller medication inconsistently, and resorted to alternative strategies to manage symptoms. Sentiment was not significantly correlated with assessed control (β = 0.14, P = 0.28), but for teens reporting severe symptoms, sentiment scores decreased by 0.31 relative to teens without symptoms (P = 0.006).

CONCLUSIONS AND CLINICAL RELEVANCE

Teens may minimize symptoms and have greater symptom frequency and severity than is recognized by themselves or providers. Screening for specific symptoms including coughing, throat clearing, and respiratory illness may be needed to identify those experiencing burden from asthma.

Adherence to Polyethylene Glycol Treatment in Children with Functional Constipation Is Associated with Parental Illness Perceptions, Satisfaction with Treatment, and Perceived Treatment Convenience

OBJECTIVES

To assess treatment adherence in children with functional constipation and to evaluate the association with parental beliefs about medication, illness perceptions, treatment satisfaction, and satisfaction with information about medication.

STUDY DESIGN

A cross-sectional survey was administered among parents of children with functional constipation treated with polyethylene glycol. Adherence was measured via the Medication Adherence Report Scale (MARS-5, score 5-25), with greater scores indicating better adherence (scores ≥23 were defined as adherent). Beliefs about medication, illness perceptions, satisfaction with treatment, and satisfaction with information about treatment were measured with the Beliefs about Medication Questionnaire, the Brief Illness Perception Questionnaire, the Treatment Satisfaction Questionnaire for Medication (TSQM), and the Satisfaction with Information about Medication Questionnaire. Associations between the questionnaire scores and adherence (MARS-5 score as a continuous variable) were analyzed with regression analyses.

RESULTS

In total, 43 of 115 included children (37%) were adherent (MARS-5 ≥23). Spearman rank correlation test revealed a statistically significant correlation between TSQM-convenience, TSQM-satisfaction, Brief Illness Perception Questionnaire question 8 (emotions), and the MARS-5 score (r_s 0.342, P = .000; r_s 0.258, P = .006; r_s -0.192, P = .044), which suggests that parental perceived treatment convenience, satisfaction with treatment, and illness perceptions may affect adherence in children with functional constipation. In the hierarchical multivariate regression model, 22% of the variability of the MARS-5 score could be explained by the selected predictors. The TSQM-convenience score contributed the most to the model (β: 0.384, P = .000).

CONCLUSIONS

Parents reported low adherence rates in their children with functional constipation. Treatment inconvenience, dissatisfaction with treatment, and the emotional impact of functional constipation may negatively influence treatment adherence.

Treatment perceptions in patients with asthma: Synthesis of factors influencing adherence

BACKGROUND

Non-adherence to asthma treatment is a contributing factor for poorly controlled asthma.

AIM

The aim of this systematic review is to explore patients' perceptions of their inhaled asthma treatment, and how these relate to adherence, using both qualitative and quantitative data.

METHODS

Pre-determined search terms and inclusion criteria were used to search electronic databases (The Cochrane Library, MEDLINE, EMBASE and PsycINFO). Two researchers screened titles and abstracts using the Rayyan web app and data were extracted in relation to psychological components (beliefs about, and attitudes towards, medicines) and adherence.

RESULTS

Of 1638 papers, 36 met the inclusion criteria. Key themes were: Perceived need for treatment - all 12 studies using the BMQ to measure patients' perceived need for treatment found that patients' beliefs about their necessity for treatment were associated with adherence-; Concerns about treatment - immediate and long-term side effects (58%), worries about safety (19%), and potential addiction to asthma medication (31%)-; and Perceived social stigma - 22% of studies reported that embarrassment contributed to poor adherence.

CONCLUSIONS

Acknowledging and addressing patient treatment beliefs and perceptual barriers to adherence is integral to designing adherence interventions for asthma patients. Further research is needed to better our understanding of the relationship between treatment perceptions and adherence.

Knowledge of Inhaled Therapy and Responsibility for Asthma Management Among Young Teens With Uncontrolled Persistent Asthma

OBJECTIVES

To compare the abilities of teens with uncontrolled persistent asthma and their caregivers to identify inhaled medications and state correct indications for use; examine medication responsibility within dyads; and determine whether responsibility is associated with knowledge about inhaled therapies.

METHODS

In the baseline survey for the School-Based Asthma Care for Teens (SB-ACT) trial, we separately asked caregivers and teens to: 1) identify the teen's inhaled asthma therapies by name and from a picture chart (complete matches considered "concordant"); 2) describe indications of use for each medication; and 3) describe the allocation of responsibility for medication use within dyads. We limited analyses to dyads in which either member reported at least one rescue and one inhaled controller medication; we used McNemar and Pearson chi-square tests.

RESULTS

A total of 136 dyads were analyzed. More caregivers than teens concordantly identified medications (63% vs 31%, P < .001). There was no difference between caregivers and teens in the ability to state correct indications for use (56% vs 54%, P = .79). More teens than caregivers endorsed "full teen responsibility" for rescue medication (65% vs 27%, P < .001) and controller medication use (50% vs 15%, P < .001). Neither concordant identification nor knowing indications for use was associated with reported medication responsibility.

CONCLUSIONS

Medication responsibility within dyads of caregivers and teens with persistent asthma is not associated with knowledge about inhaled therapies. Targeting both members of the dyad with education and self-management strategies before responsibility transitions start may allow providers to avoid a missed opportunity to support these emerging stakeholders to adherence.

Cognitive factors predict medication adherence and asthma control in urban adolescents with asthma

PURPOSE

Adolescents with asthma often report poor medication adherence and asthma control. Cognitive factors embedded in the social cognitive theory including self-efficacy, outcome expectations, and barrier perceptions may explain poor asthma outcomes in this population. This study was performed to examine the extent to which these cognitive factors are intercorrelated and explain medication adherence and asthma control in urban adolescents.

PATIENTS AND METHODS

A total of 373 urban adolescents (12-20 years) with asthma completed questionnaires measuring asthma-related self-efficacy, outcome expectations, barrier perceptions, medication adherence, and asthma control. Multiple linear regression was conducted to examine the extent to which the three cognitive factors predicted medication adherence and asthma control after controlling for covariates including age, sex, household income, and age at diagnosis.

RESULTS

Participants' ages were on average 14.68 (±1.94) years; 50% were female, and most (78.6%) were African American. Higher self-efficacy associated with lower barrier perceptions and higher outcome expectations (r=0.50, p<0.001; r=-0.26, p<0.001, respectively). Self-efficacy predicted better asthma control (B=-0.098, p=0.004) and adherence (B=0.426, p=0.011), whereas barrier perceptions predicted poorer asthma control (B=0.13, p<0.001) and adherence (B=-0.568, p<0.001). Self-efficacy independently predicted fewer missed doses (B=-0.621, p=0.006), and barrier perception independently predicted asthma control (B=0.12, p<0.001) and adherence (B=-0.519, p<0.001).

CONCLUSION

Improving medication adherence and asthma control among adolescents may require a multifaceted approach. Interventions focused on increasing self-efficacy and addressing barriers, actual or potential, to medication adherence could ameliorate asthma disparities in urban adolescents.

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.

Developing pictorial asthma action plans to promote self-management and health in rural youth with asthma: A qualitative study

OBJECTIVE

Asthma action plans (AAPs) provide asthma management instructions to families; however, AAPs typically are written at a 7th-9th grade reading level, making them less useful in lower literacy families. There is a need to develop simpler AAP formats and content to optimize their utility across all families, including those who are rural and may be at a risk for literacy concerns. Because using pictures can simplify and enhance health education, our study's aim was to develop a pictorial AAP through a series of focus groups with key stakeholders - youth with asthma, caregivers, and physicians.

METHODS

Fourteen caregiver/youth dyads and four physicians participated in separate focus groups where their preferences for pictorial AAP structure and content were obtained. Focus groups were audio recorded, transcribed, coded with ATLAS.ti, and analyzed for themes.

RESULTS

Youth and their caregivers prefer that the AAPs include simple, cartoon-like pictures customized to the patient. Physicians emphasized AAP's capability to display pictures of controller medication given its importance in preventing asthma exacerbations. A stoplight format, currently used in most written AAPs, received positive reviews. Specific suggestions for pictures showing symptoms, medications, and how to take medication were suggested. Words and short phrases accompanying the pictures were thought to add clarity.

CONCLUSIONS

Key stakeholders viewed pictorial AAPs as positive and potentially effective alternatives to standard written AAPs. It is expected that low literacy youth and caregivers would more easily understand a pictorial AAP presentation, which should facilitate better medication adherence and asthma outcomes in these children.

Transition clinic attendance is associated with improved beliefs and attitudes toward medicine in patients with inflammatory bowel disease

AIM

To evaluated the differences in knowledge, adherence, attitudes, and beliefs about medicine in adolescents with inflammatory bowel disease (IBD) attending transition clinics.

METHODS

We prospectively enrolled patients from July 2012 to June 2013. All adolescents who attended a tertiary-centre-based dedicated IBD transition clinic were invited to participate. Adolescent controls were recruited from university-affiliated gastroenterology offices. Participants completed questionnaires about their disease and reported adherence to prescribed therapy. Beliefs in Medicine Questionnaire was used to evaluate patients’ attitudes and beliefs. Beliefs of medication overuse, harm, necessity and concerns were rated on a Likert scale. Based on necessity and concern ratings, attitudes were then characterized as accepting, ambivalent, skeptical and indifferent.

RESULTS

One hundred and twelve adolescents were included and 59 attended transition clinics. Self-reported adherence rates were poor, with only 67.4% and 56.8% of patients on any IBD medication were adherent in the transition and control groups, respectively. Adolescents in the transition cohort held significantly stronger beliefs that medications were necessary (P = 0.0035). Approximately 20% of adolescents in both cohorts had accepting attitudes toward their prescribed medicine. However, compared to the control group, adolescents in the transition cohort were less skeptical of (6.8% vs 20.8%) and more ambivalent (61% vs 34%) (OR = 0.15; 95%CI: 0.03-0.75; P = 0.02) to treatment.

CONCLUSION

Attendance at dedicated transition clinics was associated with differences in attitudes in adolescents with IBD.

Perceptions and experiences underlying self-management and reporting of symptoms in teens with asthma

BACKGROUND

Teens often have inadequate asthma self-management and control. However, little is known of their perceptions of or rationales for self-management behaviors.

OBJECTIVES

To explore how teens self-manage asthma, including experiences, perceptions, responses to and reporting of symptoms.

METHODS

A case-based, qualitative-descriptive design was used. Data were collected from minority and non-minority teens with controlled and uncontrolled asthma and their respective parents (N = 28). There were four data-collection points, including: (1) a primary teen interview; (2) parent interview; (3) 2-week self-management voice-diary; and (4) follow-up teen interview, incorporating symptom-response card-sorting to map symptoms and associated self-management responses. Seventy data sources were included in the analysis.

RESULTS

Teens thought of their asthma symptoms as normal or unusual relative to their personal baseline symptom pattern; Those with uncontrolled asthma normalized higher levels of asthma symptoms than their counterparts with controlled asthma. Second, teens' decisions to treat symptoms of asthma with rescue medication were based on perceived benefits, burdens and accessibility of treatment balanced against perceived normalcy of symptoms. Teens with uncontrolled asthma had substantially higher treatment thresholds and delayed responses to symptoms compared to controlled peers. Third, teens never reported perceived normal symptoms of asthma to parents or providers, who were thus only aware of unusual or visible/audible symptoms.

CONCLUSIONS

Teen's perceptions of symptoms and understanding of what is normal is the basis for self-management decisions. Improving self-management will likely entail modifying perceptions of symptoms and benefits/burdens of treatment to achieve healthier self-management patterns.

Beliefs regarding medication and side effects influence treatment adherence in adolescents with attention deficit hyperactivity disorder

Adherence to attention deficit hyperactivity disorder (ADHD) treatment is important because, when untreated, it may have serious consequences with lifelong effects. In the case of adolescents on long-term medicine prescription, more knowledge is needed regarding adherence and factors influencing adherence, which was the purpose of this study. Adolescents (n = 101) on ADHD medication ≥6 months were administrated questionnaires at a monitoring appointment: Medication Adherence Report Scale (MARS), beliefs about medicines (BMQ) and the Brief Illness Perception Questionnaire (B-IPQ). Adherence was high, the mean value was 88% of the maximum MARS score, and correlated positively with the "BMQ-necessity-concerns differential" but negatively with "BMQ-concerns" and "BMQ-side effects". Adolescents with more belief in the necessity of the medication, less concerns and less experience of side effects tended to be more adherent to medication prescription ("intentional non-adherence"), while "unintentional non-adherence" (forgetfulness) was associated with how much they perceived that their ADHD affected their lives. In a multiple regression model, the variance of MARS total (R ² = 0.21) and "intentional non-adherence" (R ² = 0.24) was explained by the "BMQ-necessity-concern differential" and "BMQ-experienced side effects". The variance of "unintentional non-adherence" (R ² = 0.12) was explained by the "BMQ-necessity-concern differential" and "B-IPQ-consequences of ADHD". In conclusion, adolescents on long-term medication reported good adherence, mainly influenced by more beliefs in the necessity versus concerns of the medications, less experienced side effects and more perceived consequences of ADHD. BMQ could be useful to identify risks of low adherence, which should be counteracted by partially gender-specific interventions.

mHealth intervention to support asthma self-management in adolescents: the ADAPT study

PURPOSE

Poor medication adherence in adolescents with asthma results in poorly controlled disease and increased morbidity. The aim of the ADolescent Adherence Patient Tool (ADAPT) study is to develop an mHealth intervention to support self-management and to evaluate the effectiveness in improving medication adherence and asthma control.

INTERVENTION

The ADAPT intervention consists of an interactive smartphone application (app) connected to a desktop application for health care providers, in this study, the community pharmacist. The app contains several functions to improve adherence as follows: 1) a questionnaire function to rate asthma symptoms and monitor these over time; 2) short movie clips with medication and disease information; 3) a medication reminder; 4) a chat function with peers; and 5) a chat function with the pharmacist. The pharmacist receives data from the patient's app through the desktop application, which enables the pharmacist to send information and feedback to the patient.

STUDY DESIGN

The ADAPT intervention is tested in a community pharmacy-based cluster randomized controlled trial in the Netherlands, aiming to include 352 adolescents with asthma. The main outcome is adherence, measured by patient's self-report and refill adherence calculated from pharmacy dispensing records. In addition, asthma control, illness perceptions, medication beliefs, and asthma-related quality of life are measured.

CONCLUSION

This study will provide in-depth knowledge on the effectiveness of an mHealth intervention to support asthma self-management in adolescents. These insights will also be useful for adolescents with other chronic diseases.