Methodological challenges in systematic reviews of mHealth interventions: Survey and consensus-based recommendations

OBJECTIVE

Mobile Health (mHealth) refers to using mobile devices to support health. This study aimed to identify specific methodological challenges in systematic reviews (SRs) of mHealth interventions and to develop guidance for addressing selected challenges.

STUDY DESIGN AND SETTING

Two-phase participatory research project. First, we sent an online survey to corresponding authors of SRs of mHealth interventions. On a five-category scale, survey respondents rated how challenging they found 24 methodological aspects in SRs of mHealth interventions compared to non-mHealth intervention SRs. Second, a subset of survey respondents participated in an online workshop to discuss recommendations to address the most challenging methodological aspects identified in the survey. Finally, consensus-based recommendations were developed based on the workshop discussion and subsequent interaction via email with the workshop participants and two external mHealth SR authors.

RESULTS

We contacted 953 corresponding authors of mHealth intervention SRs, of whom 50 (5 %) completed the survey. All the respondents identified at least one methodological aspect as more or much more challenging in mHealth intervention SRs than in non-mHealth SRs. A median of 11 (IQR 7.25-15) out of 24 aspects (46 %) were rated as more or much more challenging. Those most frequently reported were: defining intervention intensity and components (85 %), extracting mHealth intervention details (71 %), dealing with dynamic research with evolving interventions (70 %), assessing intervention integrity (69 %), defining the intervention (66 %) and maintaining an updated review (65 %). Eleven survey respondents participated in the workshop (five had authored more than three mHealth SRs). Eighteen consensus-based recommendations were developed to address issues related to mHealth intervention integrity and to keep mHealth SRs up to date.

CONCLUSION

mHealth SRs present specific methodological challenges compared to non-mHealth interventions, particularly related to intervention integrity and keeping SRs current. Our recommendations for addressing these challenges can improve mHealth SRs.

Sleep mHealth Applications and Behavior Change Techniques Evaluation

OBJECTIVES

Mobile health apps may be an effective way to increase sleep management skills. Although little has been documented about the content and quality of available sleep management apps, providers often make app recommendations to help with sleep self-management. The objective of this study was to systematically evaluate the content and quality of commercially available sleep apps.

METHODS

Following a systematic search of the Apple App and Google Play stores, 56 sleep management apps were evaluated. App content was evaluated using the taxonomy of behavior change techniques (BCTs), and app quality was assessed using the Mobile App Rating Scale.

RESULTS

Sleep management apps included 0-15 BCTs (M = 6.89) and 0-9 sleep BCTs (M = 4.87). App quality ranged from 2.51 to 4.80 (M = 3.78) out of 5.00. Sleepiest Sleep Sounds Stories, ShutEye: Sleep Tracker, and Mintal Tracker: Sleep Recorder included the highest number of sleep BCTs and highest quality scores.

CONCLUSIONS

While the content and quality of sleep management apps is variable, the findings are promising as many apps included a high number of BCTs and high quality. Although evidence of efficacy through randomized controlled trials is necessary to establish efficacy, this review can aid in app selection in the interim.

Children with uncontrolled asthma from economically disadvantaged neighborhoods: Needs assessment and the development of a school-based telehealth and electronic inhaler monitoring system

BACKGROUND

Children from economically disadvantaged communities often encounter healthcare access barriers, increasing risk for poorly controlled asthma and subsequent healthcare utilization. This highlights the need to identify novel intervention strategies for these families.

OBJECTIVE

To better understand the needs and treatment preferences for asthma management in children from economically disadvantaged communities and to develop a novel asthma management intervention based on an initial needs assessment and stakeholder feedback.

METHODS

Semistructured interviews and focus groups were conducted with 19 children (10-17 years old) with uncontrolled asthma and their caregivers, 14 school nurses, 8 primary care physicians, and three school resource coordinators from economically disadvantaged communities. Interviews and focus groups were audio-taped and transcribed verbatim and then analyzed thematically to inform intervention development. Using stakeholder input, an intervention was developed for children with uncontrolled asthma and presented to participants for feedback to fully develop a novel intervention.

RESULTS

The needs assessment resulted in five themes: (1) barriers to quality asthma care, (2) poor communication across care providers, (3) problems identifying and managing symptoms and triggers among families, (4) difficulties with adherence, and (5) stigma. A proposed video-based telehealth intervention was proposed to stakeholders who provided favorable and informative feedback for the final development of the intervention for children with uncontrolled asthma.

CONCLUSIONS

Stakeholder input and feedback provided information critical to the development of a multicomponent (medical and behavioral) intervention in a school setting that uses technology to facilitate care, collaboration, and communication among key stakeholders to improve asthma management for children from economically disadvantaged neighborhoods.

Use of Behavior Change Techniques and Quality of Commercially Available Inflammatory Bowel Disease Apps

BACKGROUND

Inclusion of evidence-based behavior change techniques (e.g., self-monitoring) in mobile health apps has the potential to promote adherence to inflammatory bowel disease treatment. While inflammatory bowel disease management apps exist, the extent to which they incorporate behavior change techniques remains unknown.

AIMS

The present study systematically evaluated the content and quality of free, commercially available inflammatory bowel disease management apps.

METHODS

Apps were identified using a systematic search of the Apple App and Google Play stores. Apps were evaluated using Abraham and Michie's taxonomy of 26 behavior change techniques. A literature search was conducted to identify behavior change techniques specific and relevant for people with inflammatory bowel disease. App quality was assessed using the Mobile App Rating Scale with scores ranging from 1 (Inadequate) to 5 (Excellent).

RESULTS

A total of 51 inflammatory bowel disease management apps were evaluated. Apps included 0-16 behavior change techniques (Mean = 4.55) and 0-10 inflammatory bowel disease management behavior change techniques (Mean = 3.43). App quality ranged from 2.03 to 4.62 (Mean = 3.39) out of 5.00. Two apps, My IBD Care: Crohn's & Colitis and MyGiHealth GI Symptom Tracker, included the highest number of overall and inflammatory bowel disease management behavior change techniques along with high-quality scores. Bezzy IBD was the only app with a high number of overall and inflammatory bowel disease management behavior change techniques with a primary focus on social support/change.

CONCLUSION

Most inflammatory bowel disease management apps reviewed included evidence-based inflammatory bowel disease management behavior change techniques.

Systematic Evaluation of the Behavior Change Techniques and Quality of Commercially Available Cancer Self-Management Apps

PURPOSE

Apps have the potential to aid in cancer self-management, but there is limited guidance available for selecting among currently available options. The purpose of this study is to evaluate the behavior change techniques (BCTs) and quality of publicly available cancer self-management apps.

METHODS

Cancer self-management apps were identified from the Apple and Google Play stores in April 2022. Trained study team members coded the BCTs included in each app and rated its quality using the Mobile App Rating Scale (MARS). BCTs supported by previous literature were coded as cancer management BCTs.

RESULTS

The 39 apps meeting inclusion criteria included an average of 5.85 BCTs (standard deviation [SD], 3.49; range, 0-15) and 3.54 cancer management BCTs (SD, 1.90; range, 0-8). The most commonly included BCTs were educational or informational strategies: provide information about behavior-health link, provide instruction, and provide information on consequences. The overall app quality ranged from 1.69 to 4.20 (M, 3.29; SD, 0.67).

CONCLUSION

No cancer self-management apps were of excellent quality, and less than half included multiple cancer management BCTs beyond education. Clinical implications are discussed, and opportunities to improve the content and quality of apps to address the critical self-management needs of patients diagnosed with cancer are highlighted.

Diversity, Equity, and Inclusion within Pediatric Adherence Science

Given the long-standing history of systemic racism in psychological science, diversity, equity, and inclusion (DEI) efforts are increasingly vital to the advancement and improvement of the field. This commentary extends the seminal work of the article Upending Racism in Psychological Science: Strategies to Change How Our Science is Conducted, Reported, Reviewed, and Disseminated (Buchanan et al., Am Psychol, https://doi.org/10.31234/osf.io/6nk4x , 2020) by providing tangible applications and recommendations to improve DEI integration into pediatric adherence science. Real-world adherence examples are discussed regarding the challenges faced in systematically integrating DEI principles, potential solutions to overcoming barriers, and the implications of these efforts on scientific advancement in an effort to address and dismantle research practices that perpetuate inequity and White supremacy. Specifically, we provide discourse and practical guidance related to the conduct, reporting, reviewing, and dissemination of pediatric adherence science to promote dialog and produce actionable change toward the promotion of health equity and social justice.

Adherence and Self-management Interventions among Systemically Marginalized and Underserved Youth with Asthma

Objective

Asthma disproportionately impacts youth who have been systemically marginalized and underserved, henceforth termed underserved for brevity. Disparities are driven by systemic and structural racism and social determinants of health. We aimed to synthesize findings from interventions delivered among youth who have been underserved, highlight effective intervention strategies, and provide recommendations to promote health equity. To demonstrate, we also present a case example of clinical application.

Methods

We conducted a systematic literature search of randomized trials among youth (≤18 years old) who are often underserved, delivered in clinical, community, or home-based settings with medication adherence and/or self-management behaviors as an intervention outcome. We used descriptive statistics to synthesize study characteristics and outcomes.

Results

Twenty four articles, representing 21 unique interventions, met inclusion criteria. Forty-six percent reported significant improvements in adherence or self-management for the intervention group. Self-management interventions focused on symptom recognition and monitoring demonstrated the greatest percentage of significant intervention findings (71.4%); controller medication adherence interventions demonstrated the fewest (33.3%).

Conclusions

Interventions are not consistently effective for youth who have been underserved. Findings suggest that pediatric psychologists can help patients from underserved backgrounds by bolstering symptom recognition and monitoring skills, providing self-management skill education, and problem-solving ways to reduce triggers through individually tailored, multicomponent approaches. Pediatric psychologists should simultaneously strive to consider and address systemic, structural, and social determinants of asthma disparities in their work.

Technology-Assisted Stepped-Care to Promote Adherence in Adolescents with Asthma: A Pilot Study

To examine the feasibility, acceptability, and preliminary efficacy of a technology-assisted stepped-care behavioral intervention to improve adherence in adolescents with asthma. Thirty adolescents (M_age = 14.66, 53% male) with moderate to severe-persistent asthma completed daily adherence monitoring and medication reminders via a mobile app (Step 1). Participants with < 68% adherence during Step 1 received a telehealth behavioral intervention (Step 2). Twenty-six of 30 participants (87%) completed Step 1. Step 2 was indicated for 18 participants and was completed by 17. Participants favorably rated their experience in the study. Improvements in adherence (40–58%, p = .048) and decreases in asthma composite severity scores (CASI 6.08–5.08, p = .023) were observed for the full sample. Technology-assisted stepped-care is feasible and acceptable. Participants demonstrated improved adherence and asthma composite severity scores once they received the appropriate step of the intervention. Future studies should include a control group, a longer time-frame and an intermediate intervention step.

Treatment by biomarker-informed endotype vs guideline care in children with difficult-to-treat asthma

BACKGROUND

Asthma is heterogeneous, contributing to difficulty in disease management.

OBJECTIVE

To develop a biomarker-informed treatment model for difficult-to-treat (DTT) asthma and conduct a pilot feasibility study.

METHODS

School-aged children (n = 21) with DTT asthma were enrolled and completed 3 medical visits (V1-V3). V2 and V3 were completed approximately 3.5 months and 12 months after V1, respectively. At V1, guideline care and adherence interventions were initiated, and blood samples were collected for asthma biomarker assessment. A personalized treatment algorithm was developed based on biomarkers (treatment by endotype) and was implemented at V2. Asthma outcomes were compared from V1 to V2 (guideline-based care) to V2 to V3 (guideline + biomarker-informed care).

RESULTS

Overall retention was 86%. There was an even distribution of participants with allergy, without allergy, and with mixed allergies. The participants received an average of 5.9 interventions (range, 3-9). The allergic phenotype was characterized by increased CDHR3 risk genotype and high transepidermal water loss. High serum interleukin-6 level was most notable in the mixed allergic subgroup. The nonallergic phenotype was characterized by vitamin D deficiency and poor steroid treatment responsiveness. The personalized treatment plans were associated with decreased emergency department visits (median, 1 vs 0; P = .04) and increased asthma control test scores (median, 22.5 vs 23.0; P = .01).

CONCLUSION

The biomarker-based treatment algorithm triggered interventions on top of guideline care in all children with DTT asthma studied, supporting the need for this type of multipronged approach. Our findings identify the minimal biomarker set that is informative, reveal that this treatment-by-endotype intervention is feasible and may be superior to guideline care alone, and provide a strong foundation for a definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04179461.

A systematic evaluation of primary headache management apps leveraging behavior change techniques

BACKGROUND

Mobile health apps have the potential to promote adherence to headache management through the use of evidence-based behavior change techniques (e.g., self-monitoring). While many headache management apps exist, the extent to which these apps include behavior change techniques remains unknown. Thus, the present study systematically evaluated the content and quality of commercially available headache management apps.

METHODS

Headache apps were identified using a systematic search in the Apple App and Google Play stores. A total of 55 apps were evaluated using the taxonomy of behavior change techniques and app quality using the Mobile App Rating Scale.

RESULTS

Headache management apps included 0-14 behavior change techniques (Mean [M] = 5.89) and 0-8 headache management behavior change techniques (M = 4.29). App quality ranged from 2.84-4.67 (M = 3.73) out of 5.00. Three apps, Migraine Trainer, Easeday: Headache & Migraine, and PainScale, included the highest number of overall and headache management behavior change techniques along with good quality scores.

CONCLUSIONS

While randomized controlled trials are necessary to determine the efficacy of individual headache apps, most existing apps include evidence-based headache management behavior change techniques. Headache apps often focus on either self-monitoring or stress management via relaxation training, suggesting that patients' needs should be used to inform app selection.

Systematic evaluation of commercially available pain management apps examining behavior change techniques

ABSTRACT

Mobile health (mHealth) apps have the potential to enhance pain management through the use of daily diaries, medication and appointment reminders, education, and facilitating communication between patients and providers. Although many pain management apps exist, the extent to which these apps use evidence-based behavior change techniques (BCTs) remains largely unknown, making it nearly impossible for providers to recommend apps with evidence-based strategies. This study systematically evaluated commercially available pain management apps for evidence-based BCTs and app quality. Pain management apps were identified using the search terms "pain" and "pain management" in the App and Google Play stores. Reviewed apps were specific to pain management, in English, for patients, and free. A total of 28 apps were coded using the taxonomy of BCTs. App quality was assessed using the Mobile App Rating Scale. Apps included 2 to 15 BCTs (M = 7.36) and 1 to 8 (M = 4.21) pain management-specific BCTs. Prompt intention formation, instruction, behavioral-health link, consequences, feedback, and self-monitoring were the most common BCTs used in the reviewed apps. App quality from the Mobile App Rating Scale ranged from 2.27 to 4.54 (M = 3.65) out of a possible 5, with higher scores indicating better quality. PainScale followed by Migraine Buddy demonstrated the highest number of overall and pain management BCTs as well as good quality scores. Although existing apps should be assessed through randomized controlled trials and future apps should include capabilities for electronic medical record integration, current pain management apps often use evidence-based pain management BCTs.

Patient-Reported Outcomes for Pediatric Adherence and Self-Management: A Systematic Review

OBJECTIVE

Treatment adherence is approximately 50% across pediatric conditions. Patient-reported outcomes (PROs) are the most common method of measuring adherence and self-management across research and clinical contexts. The aim of this systematic review is to evaluate adherence and self-management PROs, including measures of adherence behaviors, adherence barriers, disease management skills, and treatment responsibility.

METHODS

Following PRISMA guidelines for systematic reviews, literature searches were performed. Measures meeting inclusion/exclusion criteria were evaluated using Hunsley and Mash's (2018) criteria for evidence-based assessment across several domains (e.g., internal consistency, interrater reliability, test-retest reliability, content validity, construct validity, validity generalization, treatment sensitivity, and clinical utility). Rating categories were adapted for the present study to include the original categories of adequate, good, and excellent, as well as an additional category of below adequate.

RESULTS

After screening 172 articles, 50 PROs across a variety of pediatric conditions were reviewed and evaluated. Most measures demonstrated at least adequate content validity (n = 44), internal consistency (n = 34), and validity generalization (n = 45). Findings were mixed regarding interrater reliability, test-retest reliability, and treatment sensitivity. Less than half of the measures (n = 22) exhibited adequate, good, or excellent construct validity.

CONCLUSIONS

Although use of adherence and self-management PROs is widespread across several pediatric conditions, few PROs achieved good or excellent ratings based on rigorous psychometric standards. Validation and replication studies with larger, more diverse samples are needed. Future research should consider the use of emerging technologies to enhance the feasibility of broad implementation.

Using Electronic Monitoring Devices to Assess Medication Adherence: a Research Methods Framework

While electronic adherence monitoring devices (EAMDs) are the preferred and most objective medication adherence measurement strategy for many populations and research questions, there is no comprehensive methodological framework for EAMD use. We synthesize recommendations from experts in adherence science and the scientific literature to create a temporal framework of EAMD research methods. The goal of this framework is to provide a step-by-step guide that will enable researchers to design, prepare, implement, and clean data from rigorous, high-quality studies using EAMDs to assess adherence. Resources including a checklist of methodological considerations and example protocols have been created to assist readers in using this framework.

Telehealth delivery of adherence and medication management system improves outcomes in inner-city children with asthma

Healthcare disparities exist in pediatric asthma in the United States. Children from minority, low-income families in inner-city areas encounter barriers to healthcare, leading to greater rates of poorly controlled asthma and healthcare utilization. Finding an effective way to deliver high-quality healthcare to this underserved population to improve outcomes, reduce morbidity and mortality, and reduce healthcare utilization is of the utmost importance. The purpose of this study was to assess the feasibility and efficacy of a novel school-based care delivery model that incorporates video-based telehealth (VBT) medical and self-management visits with electronic inhaler monitoring to improve asthma outcomes. Over a 6-month period, children from inner-city, low-income schools with uncontrolled asthma completed seven scheduled medical visits with an asthma specialist and five self-management visits with an adherence psychologist at school using VBT. Composite Asthma Severity Index (CASI) scores and electronic inhaler monitor data were recorded and analyzed. A total of 21 patients were enrolled in the study. Study subjects with higher baseline severity (CASI ≥ 4 at visit 1) demonstrated a greater reduction in their score than those with lower baseline severity (CASI < 4 at visit 1). The CASI domains showed improvement in daytime symptoms, nighttime symptoms, and exacerbations. Adherence results demonstrated a significant improvement in adherence from baseline to postintervention. Study retention was 100%. This study demonstrates that a multicomponent medical and behavioral interventional program delivered by VBT to a school-based setting is feasible and can significantly improve asthma outcomes and care in a challenging population.

Systematic Review of Digital Interventions for Pediatric Asthma Management

BACKGROUND

Pediatric patients with asthma take only approximately half of their prescribed medication. Digital interventions to improve adherence for youth with asthma exist and have the potential to improve accessibility, cost-effectiveness, and customizability.

OBJECTIVE

To systematically review published research examining digital interventions to promote adherence to the treatment of pediatric asthma.

METHODS

A systematic search of the PubMed, Scopus, CINAHL, PsycINFO, and reference review databases was conducted. Articles were included if adherence was an outcome in a randomized controlled trial of a digital intervention for children with asthma. We compared samples, intervention characteristics, adherence measurement and outcomes, as well as additional health outcomes across studies.

RESULTS

Of the 264 articles reviewed, 15 studies met inclusion criteria and were included in the review. Overall, 87% of the digital interventions demonstrated improved adherence and 53% demonstrated improved health outcomes. All the promising interventions included a behavioral component and most were 3 to 6 months in length, delivered through a digital stand-alone medium (eg, automated personalized texts, mobile health apps, and website), and assessed adherence to controller medication.

CONCLUSIONS

Overall, digital interventions aimed at improving adherence are promising and also improve health outcomes in addition to medication adherence. Although future studies using evidence-based adherence assessment and multifactorial design should be conducted, the current literature suggests that both digital stand-alone interventions and interventions combining digital technology with support from a health care team member result in improved adherence and asthma outcomes. Recommendations for digital interventions for pediatric patients with asthma with adherence concerns are provided.

A Systematic Evaluation of Asthma Management Apps Examining Behavior Change Techniques

BACKGROUND

Mobile health (mHealth) apps have the potential to facilitate asthma self-management by including medication reminders, allowing self-monitoring of symptoms, improving access and quality of information communicated with provider, and providing educational resources to patients and parents. Many apps exist for asthma management; however, the extent to which apps include evidence-based behavior change strategies has not been examined.

OBJECTIVE

To review the content and quality of mHealth asthma management apps that are available to patients.

METHODS

Asthma apps were identified using a systematic search process. Twenty-three apps were coded for presence or absence of behavior change techniques (BCTs) using the taxonomy of BCTs as defined by Abraham and Michie in 2008. Quality ratings were also determined for each app using the Mobile App Rating Scale (MARS).

RESULTS

The number of BCTs each app used ranged from 1 to 11 (mean, 4). BCTs that were most commonly used were instruction, behavior-health link, self-monitoring, feedback, teach to use prompts/cues, consequences, and others' approval. Overall app quality based on MARS scores ranged from 2.45 to 4.50 (mean, 3.32). Two apps, Kiss myAsthma and AsthmaMD, used at least 8 BCTs and had high quality ratings.

CONCLUSIONS

Kiss myAsthma and AsthmaMD used at least 8 BCTs and had good quality scores.

The Stability and Influence of Barriers to Medication Adherence on Seizure Outcomes and Adherence in Children With Epilepsy Over 2 Years

Objective

To determine the stability and influence of adherence barriers on medication adherence and seizure control in pediatric epilepsy.

Methods

Caregivers of 118 children aged 2-12 years old with epilepsy completed the Pediatric Epilepsy Medication Self-Management Questionnaire at nine time points over 2 years post diagnosis. Electronically monitored antiepileptic drug adherence and seizure outcome data were collected.

Results

Hierarchical linear modeling results for overall barriers remained stable over 2 years. Specific item-level barriers were also generally stable over time, with the exception of running out of medication becoming more of a barrier over time. No specific barriers were related to seizure control; however, difficulties swallowing medication, forgetting, and medication refusal were related to electronically monitored adherence over time.

Conclusions

Assessing for specific adherence barriers over time may lead to identification of interventions that result in improved adherence and care.

Examination of the uses, needs, and preferences for health technology use in adolescents with asthma

Objective: To examine the health technology uses and preferences of adolescents with asthma using a qualitative descriptive individual interview approach. Methods: Twenty adolescents were recruited from regularly scheduled asthma clinic appointments from February to July 2016. Patients were interviewed about their technology use and ways in which health technology could improve their asthma management using an open-ended semi-structured interview format. Interviews were audio recorded, transcribed, and coded into themes. Results: Social media (e.g. Snapchat, Instagram) and general communication (e.g. messaging) were the most common uses of technology while medical reminders (e.g. appointment, refill, medication) were the most common use of health technology. Adolescents identified ways in which health technology could improve their asthma management including (1) tracking symptoms and medication, (2) medical reminders, and (3) asthma and self-management knowledge specifically related to medications and individual action plans. Other themes that emerged included a desire to customize health technology to fit with individual schedules and medical routines and use of health technology data with medical providers. Conclusions: Adolescents and parents experience a number of challenges related to managing asthma, and health technology interventions should focus on ways to improve adherence and self-management. Future research considerations and potential interventions including ways to integrate adolescent preferences with evidence-based interventions are discussed.

A pilot investigation of a mobile phone application and progressive reminder system to improve adherence to daily prevention treatment in adolescents and young adults with migraine

BACKGROUND

Effective management of migraine requires adherence to treatment recommendations; however, adolescents with migraine take their daily medications only 75% of the time. Low-cost adherence-focused interventions using technology may improve adherence, but have not been investigated.

METHODS

Thirty-five adolescents and young adults (13-21 years) with migraine participated in an AB-design pilot study to assess the use of a mobile phone adherence-promotion application ("app") and progressive reminder system. Adherence was calculated using electronic monitoring during the baseline period and medication adherence intervention.

RESULTS

Relative to baseline, adherence significantly improved during the first month of the intervention. Specifically, improvements existed for older participants with lower baseline adherence. Self-reported app-based adherence rates were significantly lower than electronically monitored adherence rates. Participants rated the intervention as acceptable and easy to use.

CONCLUSIONS

"Apps" have the potential to improve medication adherence and are a promising intervention for adolescents and young adults with low adherence. Involving parents in the intervention is also helpful. Providers should assess barriers to adherence and use of technology-based interventions, encourage parents to incorporate behavioral incentives, and provide referrals for more intensive interventions to improve long-term outcomes. Further, tracking adherence in an app may result in an underestimation of adherence. Future full-scale studies should be conducted to examine adherence promotion app interventions.

Treatment Adherence in Child and Adolescent Chronic Migraine Patients: Results From the Cognitive-Behavioral Therapy and Amitriptyline Trial

OBJECTIVES

To examine treatment adherence among children and adolescents with chronic migraine who volunteered to be in a clinical trial using 3 measures: treatment session attendance, therapy homework completion, and preventive medication use by daily diary.

MATERIALS AND METHODS

Analyses are secondary from a trial of 135 youth aged 10 to 17 years diagnosed with chronic migraine and with a Pediatric Migraine Disability Score over 20. Participants were randomly assigned to cognitive-behavioral therapy plus amitriptyline (CBT+A, N=64) or headache education plus amitriptyline (HE+A, N=71). Therapists recorded session attendance. Completion of homework/practice between sessions was reported to therapists by patients. Patients reported preventive medication adherence using a daily headache diary.

RESULTS

Mean session attendance adherence out of 10 treatment sessions was 95% for CBT+A and 99% for HE+A. CBT+A participants reported completing a mean of 90% of home practice of CBT skills between the 10 sessions. Participants reported taking amitriptyline daily at a mean level of 90% when missing diaries were excluded and 79% when missing diaries were considered as missed doses of medication.

DISCUSSION

Our findings demonstrate that youth with chronic migraine who agree to be a part of a clinical trial do quite well at attending therapy sessions, and report that they are adherent to completing home/practice between sessions and taking medication. These results lend further support to consideration of CBT+A as a first-line treatment for youth with chronic migraine and suggest that measurement of adherence when this treatment is provided in practice will be important.

Child Attitude Toward Illness Scale (CATIS): A systematic review of the literature

OBJECTIVE

The objective of this study was to systematically review the literature utilizing the Child Attitude Toward Illness Scale (CATIS) as a measure of illness attitudes within pediatric chronic illness, including epilepsy, and provide recommendations for its use. This review includes an examination of the psychometric properties of the CATIS and the relationship between the CATIS and psychological, academic, behavioral, and illness variables.

METHOD

Electronic searches were conducted using Medline and PsychINFO to identify twenty-two relevant publications.

RESULTS

The CATIS was identified as a reliable and valid self-report assessment tool across chronic illnesses, including pediatric epilepsy. Although originally developed for children ages 8-12, the CATIS has demonstrated reliability and validity in youth ages 8-22. The CATIS scores were reliably associated with cognitive appraisal variables and internalizing symptoms. Initial support exists for the relation between illness attitudes and externalizing behavior, academic functioning, and psychosocial care needs. Mixed findings were reported with regard to the relation between illness attitudes and demographic and disease variables, as well as both social and family functioning.

CONCLUSION

The CATIS is a psychometrically sound self-report instrument for measuring illness attitudes and demonstrates clinical utility for examining adjustment outcomes across chronic illnesses, particularly pediatric epilepsy.

Predictors of trajectories of epilepsy-specific quality of life among children newly diagnosed with epilepsy

OBJECTIVE

The objective of this study was to identify two-year trajectories of epilepsy-specific health-related quality of life (HRQOL) among children newly diagnosed with epilepsy and to evaluate the predictive value of a comprehensive set of medical, psychosocial, and family factors.

METHODS

Ninety-four children with epilepsy (8.14 ± 2.37 years of age and 63% male) and their caregivers participated in this study. Caregivers completed the Quality of Life in Childhood Epilepsy Questionnaire (QOLCE) and measures of psychological and family functioning at one month postdiagnosis. The QOLCE was also given at eight additional time points during the subsequent two years as a part of a large observational study in children with epilepsy. Adherence data were collected via MEMS TrackCaps, and medical information was collected through chart review.

RESULTS

Unique trajectories were identified for the overall QOLCE scale, as well as the subscales. Most trajectory models for the QOLCE subscales contained at least one at-risk trajectory for children, indicating that there is a subgroup of children experiencing poor long-term HRQOL. Health-related quality-of-life trajectories remained predominantly stable during the two-year period following treatment initiation. The number of AEDs, internalizing problems, and externalizing problems emerged as the most consistent predictors across the HRQOL domains.

SIGNIFICANCE

Medical and psychosocial interventions, such as cognitive-behavioral strategies, should target modifiable factors (e.g., internalizing symptoms, externalizing symptoms, number of AEDs trialed) shortly after diagnosis to improve HRQOL for children with epilepsy over the course of their disease.

Trajectories of Health-Related Quality of Life Among Children With Newly Diagnosed Epilepsy

OBJECTIVE

To identify two-year trajectories of health-related quality of life (HRQOL) among children with newly diagnosed epilepsy, and evaluate key predictors of HRQOL trajectories.

METHODS

This study is part of a prospective study of adherence and HRQOL outcomes in children with epilepsy. Caregivers completed an HRQOL questionnaire at one month post diagnosis and every three months thereafter for two years. Chart review and additional questionnaires were used to collect medical variables and seizure outcomes.

RESULTS

Participants included 120 children with epilepsy and their caregiver. Unique trajectories for overall HRQOL and PedsQL™ subscales were identified and were predominantly stable. A total side effects score emerged as a consistent predictor of all HRQOL domains. Other variables (i.e., socioeconomic status, seizures, internalizing and externalizing problems) uniquely predicted HRQOL domains.

CONCLUSIONS

Medical and psychosocial interventions should be implemented soon after treatment initiation to target modifiable factors (e.g., side effects, anxiety symptoms), which could improve HRQOL.

Examination of parent-child adjustment in juvenile rheumatic diseases using depression-specific indices of parent and youth functioning

Studies demonstrate a link between parental distress, youth illness appraisals, and depression symptoms in youth with juvenile rheumatic diseases. However, the exclusive use of broadband (i.e. general) measures of parental distress in these studies has resulted in conceptual and clinical imprecision regarding the parent-child adjustment process. Our aim was to reanalyze previously published data (i.e. Wagner et al., 2003) using a depression-specific scale derived from the general adult distress measure in the original study. Parents completed the Brief Symptom Inventory (BSI), youth completed the Child Depression Inventory (CDI), and the Illness Intrusiveness Scale (IIS-C). Thirteen Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) depression-specific items from the BSI comprised the parent measure of Depressive Symptoms Scale (DS). Consistent with Wagner et al. (2003), adult DS scores were associated with youth CDI scores. However, youth illness appraisals had unique effects on the parent-child depression relation. Elevated youth perceptions of illness intrusiveness amplified the negative effect of parent depressive symptoms on youth depressive symptoms; decreased illness intrusiveness buffered the negative effect of parent depression. The empirical and clinical implications of assessing parent and youth adjustment in a domain-specific manner are discussed.

Treatment adherence in patients with headache: a systematic review

OBJECTIVE

To review and critically evaluate the extant research literature pertaining to adherence in youth and adults with headache and to provide recommendations for future research.

BACKGROUND

This article provides the first systematic review of pediatric headache adherence and updates a previous review of treatment adherence in adults with headache.

DESIGN

Systematic review of empirical literature.

METHODS

A literature search with no date restriction was conducted using PubMed and PsycINFO electronic databases and bibliographies of relevant articles.

RESULTS

Adherence rates in adults with headache range considerably from 25% to 94% across treatment, assessment method, and definition of adherence utilized. Methods to assess adherence included retrospective prescription claims data, paper or electronic diaries, follow-up appointment attendance, written and verbal self-report of general adherence, verbal self-report of adherence over a specific amount of time via in person interview or telephone, validated adherence measures, adherence questionnaires without validation, and counselor ratings of homework. Each methodology and assessment tool demonstrated strengths and weaknesses. No studies have systematically examined medication adherence in children with headache, and the few available studies examining adherence to behavioral treatment have documented adherence rates ranging from 52% to 86%.

CONCLUSIONS

Adherence research in adults with headache is growing, but studies demonstrate a number of methodological shortcomings. Adherence research in children with headache, and adherence intervention research in both adults and children, is scant. Future research should use objective measures of adherence, consider over-the-counter medications and medication overuse, examine demographic, psychological, and behavioral correlates of adherence, assess adherence to botulinum toxin type A, and examine the efficacy of adherence interventions in individuals with headache.

Caregiver demand and parent distress in juvenile rheumatic disease: the mediating effect of parent attitude toward illness

Parents of youth with juvenile rheumatic diseases (JRD) often take on illness management responsibilities that can become burdensome, potentially resulting in poor parent adjustment outcomes. However, not all caregivers will experience increased distress as a result of variability in stress appraisals. The current study examined the role of parent illness attitudes in the relation between perceived caregiver demand and parental distress. Youth (N = 70) ages 7-18 years diagnosed with a JRD and their parents were recruited from a pediatric rheumatology clinic. Parents completed measures of caregiver demand, parental distress, and illness attitudes. Hierarchical regression revealed a relationship between caregiver demand and parental distress. A significant relationship was also found between caregiver demand and parent illness attitudes, as well as parent illness attitudes and parental distress. Thus, parent illness attitudes mediated the relationship between caregiver demand and parental distress. Techniques aimed at altering negative illness attitudes may help parents cope with their caregiving responsibilities.

Differences in sleep quality and health-related quality of life in young adults with allergies and asthma and their healthy peers

OBJECTIVE

The current study examined the relationship between sleep quality and health-related quality of life (HRQOL).

PARTICIPANTS

Participants were 501 undergraduate students with allergies (167), asthma + allergies (167), or with no history of a chronic illness (167) completed study measures from August 2011 to April 2012.

METHODS

The undergraduate students completed questionnaires online as part of a larger study of psychosocial adjustment of young adults.

RESULTS

Young adults with allergies and asthma + allergies reported significantly worse sleep quality and HRQOL than healthy peers. Additionally, those with allergies and asthma + allergies had significantly more sleep disturbances and used sleeping medication significantly more often in the previous month than healthy peers.

CONCLUSIONS

These results highlight concerns regarding quality of life and sleep problems in an often-overlooked population. Importantly, sleep difficulties can result in difficulties in daily living and impairment in academic functioning.

Exploration of age and sex differences in depressive symptoms and illness attitudes for youth with epilepsy and juvenile rheumatic disease

The aim was to explore the relationship of youth age and sex to depressive symptoms and illness attitudes in youth with epilepsy and juvenile rheumatic disease. Youth with epilepsy or juvenile rheumatic disease between the ages of 7 and 19 years completed measures of depressive symptoms and illness attitudes. A significant 3-way interaction, Disease Group × Sex × Age, was found when predicting depressive symptoms. Post hoc analyses revealed a simple 2-way Disease Group × Age interaction for males and females. Younger males and adolescent females with epilepsy reported greater depressive symptoms than younger males and adolescent females with a juvenile rheumatic disease. Youth with epilepsy reported more negative illness attitudes than youth diagnosed with a juvenile rheumatic disease, but no other main effects or interactions were found. Results suggest early screening of depressive symptoms, with particular attention to younger males and adolescent females with epilepsy.

Utility of the Illness Intrusiveness Scale in parents of children diagnosed with juvenile rheumatic diseases

OBJECTIVE

To examine the factor structure and convergent validity of the Illness Intrusiveness Scale--Parent Version in mother and fathers of children and adolescents ages 7 to 18 (M = 13.56 years, SD = 2.67) diagnosed with a juvenile rheumatic disease.

DESIGN

Parents of 122 children and adolescents (82 girls, 40 boys) completed the Illness Intrusiveness Scale-Parent Version, and both parents and children and adolescents completed measures of functional disability, general distress, and illness uncertainty. An exploratory factor analysis was conducted on the Illness Intrusiveness Scale--Parent Version to identify the factor structure. The factors were then compared with parent- and child-report measures of functional disability, general distress, and uncertainty. Finally, analyses were conducted to determine whether the magnitude of the correlations was significantly different between factors for parents and children and adolescents.

RESULTS

The Illness Intrusiveness Scale--Parent Version was found to have a two-factor structure. The Relationships/Personal Development factor contained items related to self-fulfillment and interactions with others, and the Instrumental factor contained items related to health and work. These factors were found to have good internal consistency and were significantly correlated with measures of parent-reported functional disability and parent- and youth-reported distress and uncertainty. The magnitude of these correlations was also found to differ depending on informant and outcome measure.

CONCLUSION

The Illness Intrusiveness Scale--Parent Version appears to be a valid measure for use in parents of children with juvenile rheumatic disease.

Evaluation of a Bayesian regression-analysis computer program using non-steady-state phenytoin concentrations

The predictive performance of a Bayesian regression-analysis computer program that uses non-steady-state phenytoin data was evaluated. Forty patients receiving phenytoin or phenytoin sodium who had two or more non-steady-state serum concentrations were selected for study. Additional serum concentrations and dosing data were collected as they became available, but no effort was made to control the number or timing of serum concentration determinations. Patients were categorized into four groups for evaluation of the effect of potential bioavailability problems and length of dosing history (time over which serum concentration-time data were collected) on the ability to predict subsequent phenytoin concentrations. Population parameters for phenytoin maximum rate of elimination (Vmax), apparent Michaelis-Menten constant (Km), volume of distribution (V), and bioavailability (F) were obtained from the literature. Predictions based on serum phenytoin concentrations and dosing histories (information intervals) of 5 or 10 days were compared with predictions based on naive (population-based) estimates using prediction-error analysis. In each patient group, the use of either 5-day or 10-day information intervals resulted in a significant increase in precision and a significant reduction in bias compared with naive estimates. For the group of patients who initially had two or more serum concentrations within the first five days of monitoring, predictions showed a marked increase in bias and a decrease in precision as the time interval from the last measured concentration to the time of prediction increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Kinetic study of platelets and fibrinogen in Lassa virus-infected monkeys and early pathologic events in Mopeia virus-infected monkeys

The rhesus monkey, an established model of Lassa fever, was used to study hematologic and hemostatic aspects of Lassa fever and whether Mopeia (also known as Mozambique) virus induces any cellular damage in this model. Six days after subcutaneous injection of 10(3.48) plaque forming units (PFU) of Lassa virus (Josiah strain) one group of monkeys received an intravenous injection of 111In-labeled allogeneic platelets and another group received 125I-labeled alogeneic fibrinogen. Lassa virus-infected monkeys developed a severe clinical illness with high viremia and typical pathology. Lassa antigen was found in most tissues using a Lassa nucleocapsid-specific monoclonal antibody. Platelet counts remained within normal limits. Platelet and fibrinogen kinetics were similar in infected and control animals. Hematologic and hemostatic changes indicate that disseminated intravascular coagulation plays no role in this model of Lassa fever. Levels of plasma fibronectin were reduced in Lassa-infected monkeys. Mopeia virus-infected monkeys were normothemic, aviremic, and there was no detection of Mopeia antigen in any tissues using polyclonal or monoclonal antibodies. Mopeia virus was recovered from the spleen of one monkey. Mopeia virus was associated with hepatocellular and renal tubular damage.