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PubMed2006

Behavioral assessment and intervention in pediatric diabetes.

This article reviews the empirical research literature on behavioral assessment and intervention methods in the context of diabetes mellitus in children and adolescents. The review summarizes the pathophysiology, medical management, and monitoring of pediatric type 1 and type 2 diabetes. Next, the article describes common behavioral barriers to acceptable diabetes management and adequate metabolic control and the role of behavior change agents in evaluation and intervention for these problems. Validated approaches to the assessment of diabetes-specific behavioral problems are described for the measurement of treatment adherence, diabetes-related fears and avoidance behaviors, diabetes-specific social skills, and disease-related stressors. Behavioral interventions that have empirical support are discussed, including treatments that target treatment adherence, social skills, coping skills, family communication and problem solving, anxiety and stress management, and weight control. The article concludes with clinical practice recommendations for behavior change specialists who have the opportunity to work with this population.

Child↗

PubMed2002

Will changing the emphasis from 'pulseless' to 'no signs of circulation' improve the recall scores for effective life support skills in children?

This study analyses, retrospectively, an established data set to measure the effect of the circulation change in European Resuscitation Council Guidelines. This prospective matched control study examined the extent to which Year 6 (10-11 years) children retained and were able to demonstrate the sequencing and assessment skills of Basic Life Support (BLS) techniques 5 months after BLS training through the Injury Minimization Programme for Schools (I.M.P.S.). A total of 1292 children were enrolled at the beginning of the study: 657 in the intervention group received BLS through I.M.P.S., 635 children in the control group received no planned intervention. Children in both groups were tested 5 months after intervention using small portable manikins. Chi-square analysis of individual variables indicated that the intervention group was better (P<0.0005) than controls in almost all areas of basic life support (BLS). 'Adequate' BLS skills, the minimum skills considered to be effective, were also demonstrated in both groups, intervention 4.1%, controls 0.5%. Recalculation of these variables removing the check on the carotid pulse resulted in an increase to 24% of adequate BLS skills in the intervention group. Conversely, only 2.1% of controls performed to this standard. With strict adherence to Resuscitation Council guidelines, 'optimal' life saving procedures (all primary BLS steps performed optimally), were initiated by very few, marginally better in the intervention than the control group, intervention 6 (1.1%) controls 0 (0%). Some children in both groups performed the cardio-pulmonary resuscitation (CPR) element of BLS in an ineffective manner. Changing the circulation assessment would seem appropriate and allow recognition of life support attempts that are beneficial if not optimal.

Cardiopulmonary Resuscitation↗

PubMed1998

Exercise and activity level in Alzheimer's disease: a potential treatment focus.

This article provides information on the baseline health and physical function of 30 individuals with Alzheimer's disease (AD); describes a community-based program designed to increase balance, flexibility, strength, and endurance in these persons by the training of caregivers to facilitate and supervise exercise activity; and documents the adherence of these subjects and their caregivers to this intervention. Subjects were recruited from an ongoing, community-based Alzheimer's Disease Patient Registry, and met NINCDS-ADRDA criteria for probable or possible AD. Caregivers were family members living with the demented individuals in the community. Physical performance was measured using walking speed, functional reach, and standing balance. Health status was measured with the Medical Outcomes Study Short Form, the Sickness Impact Profile, and caregiver reports of subject's restricted activity days, bed disability days, falls, and exercise participation. Baseline data indicated that persons with AD were impaired on measures of physical performance and function, compared to published data on nondemented older adults. During a 12-wk treatment period, caregivers were taught to guide their demented charges in an individualized program of endurance activities (primarily walking), strength training, and balance and flexibility exercises. Adherence data indicated that 100% of the subjects were compliant with some exercise recommendations, and one-third completed all assigned exercises during the training period. Caregivers were able to learn and direct subjects during scheduled exercise activities. These findings indicate that the integration of exercise training into the care of persons with AD is both needed and feasible. Further research is currently underway to determine the efficacy of this approach for reducing additional physical disability in these individuals.

Activities of Daily Living↗

PubMed2004

Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world.

Iron deficiency is the most common and widespread nutritional disorder in the world, affecting millions of people in both nonindustrialized and industrialized countries. We estimated the costs, effects, and cost-effectiveness of iron supplementation and iron fortification interventions in 4 regions of the world. The effects on population health were arrived at by using a population model designed to estimate the lifelong impact of iron supplementation or iron fortification on individuals benefiting from such interventions. The population model took into consideration effectiveness, patient adherence, and geographic coverage. Costs were based on primary data collection and on a review of the literature. At 95% geographic coverage, iron supplementation has a larger impact on population health than iron fortification. Iron supplementation would avert <12,500 disability adjusted life years (DALY) annually in the European subregion, with very low rates of adult and child mortality, to almost 2.5 million DALYs in the African and Southeast Asian subregions, with high rates of adult and child mortality. On the other hand, fortification is less costly than supplementation and appears to be more cost effective than iron supplementation, regardless of the geographic coverage of fortification. We conclude that iron fortification is economically more attractive than iron supplementation. However, spending the extra resources to implement iron supplementation is still a cost-effective option. The results should be interpreted with caution, because evidence of intervention effectiveness predominantly relates to small-scale efficacy trials, which may not reflect the actual effect under expected conditions.

Anemia, Iron-Deficiency↗

PubMed2002

The effects of physical and emotional status on adherence to a low-fat dietary pattern in the Women's Health Initiative.

OBJECTIVE: To examine whether the effects of physical and emotional status on adherance to a low-fat (20% energy) dietary pattern are mediated by participation in an intervention program (attending sessions and self-monitoring). DESIGN: The Baron and Kenny mediator model, a series of 4 regression analyses, was used to evaluate whether: a) physical and emotional status predicted program participation, b) program participation predicted dietary adherence, c) physical and emotional status factors predicted dietary adherence, and, ultimately d) the effects of physical and emotional status on dietary adherence were mediated by program participation. SUBJECTS/SETTING: Data from 13,277 postmenopausal women randomly assigned to the low-fat intervention arm of the Women's Health Initiative Dietary Modification Trial. INTERVENTION: The nutrition goals for women randomly assigned to the low-fat intervention were to reduce total fat intake to 20% or less of energy from fat and to consume 5 or more fruit/vegetable servings daily and 6 or more grain servings daily. MAIN OUTCOME MEASURES: Year 1 program participation (degree of attending group sessions and submitting fat scores) and adherence to the low-fat dietary pattern (percent energy from fat) as predicted by baseline physical and emotional status (eight SF-36 Health Survey subscales). RESULTS: Participating in the dietary intervention program reduced (mediated) the negative effect of poorer mental health on dietary adherence by 15%. Additional findings included that a 10% increase in physical functioning increased session attendance by 0.4% (P<.001) and a 10% increase in mental health predicted a decrease in percent energy from fat of 0.3% (P<.001). Program participation had a marked effect on dietary adherence: a 10% increase in session attendance predicted a 1.2% decrease in percent energy from fat (P<.001). APPLICATIONS/CONCLUSIONS: Understanding and using instruments to assess the physical and emotional status of a target population will help dietetic professionals promote healthful dietary change and maintenance.

Adult↗

PubMed2004

Psychological, behavioral, and immune changes after a psychological intervention: a clinical trial.

PURPOSE: This randomized clinical trial tests the hypothesis that a psychological intervention can reduce emotional distress, improve health behaviors and dose-intensity, and enhance immune responses. PATIENTS AND METHODS: We studied 227 women who were surgically treated for regional breast cancer. Before adjuvant therapy, women completed interviews and questionnaires assessing emotional distress, social adjustment, and health behaviors. A 60-mL blood sample was drawn for immune assays. Patients were randomly assigned to either the intervention group or assessment only group. The intervention was conducted in small patient groups, with one session per week for 4 months. The sessions included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Reassessment occurred after completion of the intervention. RESULTS: As predicted, patients receiving the intervention showed significant lowering of anxiety, improvements in perceived social support, improved dietary habits, and reduction in smoking (all P <.05). Analyses of adjuvant chemotherapy dose-intensity revealed significantly more variability (ie, more dispersion in the dose-intensity values) for the assessment arm (P <.05). Immune responses for the intervention patients paralleled their psychological and behavioral improvements. T-cell proliferation in response to phytohemagglutinin and concanavalin A remained stable or increased for the Intervention patients, whereas both responses declined for Assessment patients; this effect was replicated across three concentrations for each assay (all P <.01). CONCLUSION: These data show a convergence of significant psychological, health behavior, and biologic effects after a psychological intervention for cancer patients.

Adaptation, Psychological↗

PubMed2004

Developing a directly administered antiretroviral therapy intervention for HIV-infected drug users: implications for program replication.

Directly administered antiretroviral therapy (DAART) is one approach to improving adherence to among human immunodeficiency virus (HIV)-infected drug users. We evaluated the essential features of a community-based DAART intervention in a randomized, controlled trial of DAART versus self-administered therapy. Of the initial 72 subjects, 78% were racial minorities, and 32% were women. Social and medical comorbidities among subjects included homelessness (35% of subjects), lack of interpersonal support (86%), major depression (57%), and alcoholism (36%). At baseline, the median CD4+ cell count was 403 cells/mL and the median HIV-1 RNA load was 146,333 copies/mL (log10 5.31 copies/mL). During the prior 6 months, 33% of subjects had missed a medical appointment, and 47% had visited an emergency department. Although most subjects (67%) preferred to take their own medications, 76% would accept DAART if it were made compulsory. A methadone clinic was the DAART venue acceptable to the fewest subjects (36%), and a mobile syringe-exchange program was acceptable to the most subjects (83%). Adherence was higher for supervised than for unsupervised medication administration (P<.0001), a finding that supports use of daily supervision of once-daily regimens. Moreover, DAART should incorporate enhanced elements such as convenience, flexibility, confidentiality, cues and reminders, responsive pharmacy and medical services, and specialized training for staff.

Adult↗

PubMed2007

Exercise and biomarkers for cancer prevention studies.

The International Agency for Research on Cancer estimates that 25% of cancer cases worldwide are caused by overweight or obesity and a sedentary lifestyle. These lifestyle patterns may increase cancer risk by several mechanisms including increased estrogens and testosterone, hyperinsulinemia and insulin resistance, increased inflammation, and depressed immune function. Several randomized clinical trials have shown that physical activity and diet interventions can change biomarkers of cancer risk. In a controlled physical activity trial, we found decreases in serum estrogen, testosterone, and insulin in overweight, sedentary postmenopausal women with a 1-y exercise program consisting of moderate-intensity aerobic exercise, 45 min/d, 5 d/wk. In another controlled trial in middle-aged to older persons, we found that a 1-y exercise intervention of 60 min/d, 6 d/wk, reduced colon crypt cell proliferation in men who adhered closely to the program. Only 1 trial, the Women's Health Initiative Dietary Modification Trial, has published results of a dietary intervention on breast cancer incidence and reported a statistically nonsignificant 9% reduction in invasive breast cancer incidence in postmenopausal women following a low-fat dietary pattern for 8-12 y. Other trials under way are testing effects of weight loss, physical activity, and dietary patterns on other cancer biomarkers. The NCI-funded Transdisciplinary Research on Energetics and Cancer centers are exploring novel research into mechanisms linking energy balance with cancer risk and prevention. The worldwide trends toward increasing overweight and obesity and decreasing physical activity may lead to an increased incidence of several cancers unless other means of risk reduction counteract these effects. Thus, adoption of lifestyle changes by individuals and populations may have a large impact on the future incidence of cancer.

Biomarkers↗

PubMed2005

Do fixed-dose combination pills or unit-of-use packaging improve adherence? A systematic review.

Adequate adherence to medication regimens is central to the successful treatment of communicable and noncommunicable disease. Fixed-dose combination pills and unit-of-use packaging are therapy-related interventions that are designed to simplify medication regimens and so potentially improve adherence. We conducted a systematic review of relevant randomized trials in order to quantify the effects of fixed-dose combination pills and unit-of-use packaging, compared with medications as usually presented, in terms of adherence to treatment and improved outcomes. Only 15 trials met the inclusion criteria; fixed-dose combination pills were investigated in three of these, while unit-of-use packaging was studied in 12 trials. The trials involved treatments for communicable diseases (n = 5), blood pressure lowering medications (n = 3), diabetic patients (n = 1), vitamin supplementation (n = 1) and management of multiple medications by the elderly (n = 5). The results of the trials suggested that there were trends towards improved adherence and/or clinical outcomes in all but three of the trials; this reached statistical significance in four out of seven trials reporting a clinically relevant or intermediate end-point, and in seven out of thirteen trials reporting medication adherence. Measures of outcome were, however, heterogeneous, and interpretation was further limited by methodological issues, particularly small sample size, short duration and loss to follow-up. Overall, the evidence suggests that fixed-dose combination pills and unit-of-use packaging are likely to improve adherence in a range of settings, but the limitations of the available evidence means that uncertainty remains about the size of these benefits.

Drug Combinations↗

PubMed2006

Manualized communication interventions to enhance palliative care research and training: rigorous, testable approaches.

Palliative care practice requires excellent communication between the patient, family, and clinical team. Experts in the field have proposed a variety of communication interventions that can be used in the palliative care setting. However, these interventions are at a high level of generality: the specifics of each intervention are not well codified; the individual steps in each intervention are not easily reproducible and thus not comparable between practitioners; the methods to measure adherence to these communication protocols have not been established; and there is little detail on how to adapt these general interventions to the individual patient and family. Therefore, we lack good evidence for the efficacy of these recommendations. This paper makes the case for development of structured, testable approaches to communication that will inform clinical practice and communication training. To do so, palliative care communication should be conceived as a formal medical and psychosocial intervention-a potential treatment with risks and benefits to be systematically researched and operationalized in the same manner as medication interventions. As we illustrate, psychotherapy research has faced the same challenges in the past and has utilized manualized treatments to meet its goals. Through such approaches, we can begin to address the most basic intervention questions such as protocol efficacy, dose-response, side effects, and the optimal process and content of communication with the patient and family. The advantages of manualized communication approaches; some concepts underlying manual construction; and challenges to extending manualized communication to the palliative care domain are discussed.

Communication↗

PubMed1995

Adherence to zidovudine (AZT) among HIV-infected methadone patients: a pilot study of supervised therapy and dispensing compared to usual care.

Twenty-seven HIV-infected methadone maintenance patients who demonstrated problems adhering to zidovudine (AZT) were randomly assigned to a group that received eight weeks of weekday supervised therapy and dispensing of AZT or a group that received usual care of the clinic. Adherence was assessed by self-report, erythrocyte mean corpuscular volume (MCV), Medication Event Monitoring Systems (MEMS), and pill counts. Subjects in the intervention group demonstrated significantly higher MCV levels during the intervention period than usual care subjects, with similar but non-significant trends for the three other adherence measures. MEMS percent indicated significant group differences on weekdays, but not weekend days. There were no differences at a one-month follow-up. Results suggest supervised therapy and dispensing may be an effective strategy for improving AZT adherence, but only while provided. Further research is needed to establish the effects of larger and longer lasting interventions.

Adult↗

PubMed2000

The old problem of adherence: research on treatment adherence and its relevance for HIV/AIDS.

The international published research on patient adherence was selectively reviewed with the goal of determining its relevance for the treatment of HIV/AIDS. Results show that not adhering to treatment regimes is so widespread that no combination of sociodemographic variables is reliably predictive of patients' not following doctors' orders. Achieving 100% adherence for any treatment or patient group does not appear to be realistic. Characteristics of the patient's situation, of the given therapy, and of the disease itself affect adherence. In addition, the patient-doctor relationship and the context of the treatment are important. Often overlooked are the existential dimensions of meaning, self-determination and quality of life which are particularly important for the chronically ill. Treatment needs to be negotiated individually with each patient on the basis of an open therapeutic relationship and with the help of multidimensional interventions. Lessons from the discourse on safer sex can steer adherence research and practice away from a behavioural and reductionist approach toward the context and meaning of treatment.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Concordance: a widely used term, but what does it mean?

The term concordance was first used by the Medicines Partnership to describe a new way of consulting with patients in order to gain the most effective use of medicines (Royal Pharmaceutical Society of Great Britain 1997). Over recent years, the term has become associated with many different health care interventions. The aim of concordance is to improve satisfaction with the process of health care consultations, having the ultimate goal to reduce wastage of health care resources. Concordance has evolved from terms such as non-compliance and non-adherence and reflects a shift in the culture of health care interventions, aiming to empower patients. Suggestions to the content of concordant consultations are outlined in this article and will be further developed in the second article.

Attitude of Health Personnel↗

PubMed1998

Electronic monitoring of adherence to treatment in the preventive chemotherapy of tuberculosis.

SETTING: Non-adherence to treatment is a frequent problem in the preventive chemoprophylaxis of tuberculosis. OBJECTIVE: To evaluate the usefulness of the Medication Event Monitoring System (MEMS) for following and improving patient adherence to 6-month treatment with isoniazid. DESIGN: Three methods of monitoring compliance, MEMS, pill count and a urine test for isoniazid, were compared prospectively in 30 patients. The efficacy of a combined intervention by the physician and the pharmacist was evaluated in non-compliant patients. RESULTS: According to the MEMS data, overall adherence to isoniazid therapy was 91.5%, and 86% of the patients were considered compliant throughout the period of observation. The pill count and the urine test tended to overestimate the overall compliance when compared to the MEMS. The combined intervention of the physician and pharmacist allowed drug adherence to be enhanced in non-compliant patients, but the effect was only transient if this was not repeated every month. CONCLUSION: Our results suggest that the MEMS system is a useful approach for monitoring and improving compliance with preventive chemotherapy for tuberculosis.

Adolescent↗

PubMedDate not supplied

Impact on medication use and adherence of Australian pharmacists' diabetes care services.

OBJECTIVE: To assess the effect of a specialized service implemented in community pharmacies for patients with type 2 diabetes on medication use and medication-related problems. DESIGN: Parallel group, multisite, control versus intervention, repeated measures design, with three different regions in New South Wales, Australia, used as intervention regions, then matched with control regions as much as possible. INTERVENTION: After initial training, pharmacists followed a clinical protocol for more than 9 months, with patient contact approximately monthly. Each patient received an adherence assessment at the beginning and end of the study, adherence support, and a medication review as part of the intervention. MAIN OUTCOME MEASURES: Risk of nonadherence using Brief Medication Questionnaire (BMQ) scores and changes to medication regimen. RESULTS: Compared with 82 control patients, 106 intervention patients with similar demographic and clinical characteristics had significantly improved self-reported nonadherence as reflected in total BMQ scores after 9 months. The mean (+/-SD) number of medications prescribed at follow-up in intervention participants decreased significantly, from 8.2+/-3.0 to 7.7+/-2.7. No reduction was observed among the control patients (7.6+/-2.4 and 7.3+/-2.4). The overall prevalence of changes to the regimen was also significantly higher in the intervention group (51%) compared with controls (40%). CONCLUSION: Community pharmacists trained in medication review and using protocols in collaboration with providers improved adherence in patients with type 2 diabetes, reduced problems patients had in accessing their medications, and recommended medication regimen changes that improved outcomes.

Australia↗

PubMedDate not supplied

Improving adherence and reducing medication discrepancies in patients with diabetes.

OBJECTIVE: To improve medication adherence by reducing self-reported adherence barriers, and to identify medication discrepancies by comparing physician-prescribed and patient-reported medical regimens. DESIGN: Prospective, randomized, controlled trial. SETTING AND PARTICIPANTS: A single academically affiliated community health center. Eligible patients had type 2 diabetes, had undergone laboratory testing in the year preceding the study, and had visited the clinic in the 6 months preceding the study. INTERVENTION: A pharmacist administered detailed questionnaires, provided tailored education regarding medication use and help with appointment referrals, and created a summary of adherence barriers and medication discrepancies that was entered into the medical record and electronically forwarded to the primary care provider. MEASUREMENTS: Changes in self-reported adherence rates and barriers were compared 3 months after the initial interview. Intervention patients with medication discrepancies at baseline were assessed for resolution of discrepancies at 3 months. RESULTS: Rates of self-reported medication adherence were very high and did not improve further at 3 months (6.9 of 7 d, with all medicines taken as prescribed; p = 0.3). Medical regimen discrepancies were identified in 44% of intervention patients, involving 45 doses of medicines. At 3-month follow-up, 60% of discrepancies were resolved by corrections in the medical record, while only 7% reflected corrections by patients. CONCLUSIONS: In this community cohort, patients reported few adherence barriers and very high medication adherence rates. Our patient-tailored intervention did not further reduce these barriers or improve self-reported adherence. The high prevalence of medication discrepancies appeared to mostly reflect inaccuracies in the medical record rather than patient errors.

Aged↗

PubMed2002

Treatment of child and adolescent obesity: reports from pediatricians, pediatric nurse practitioners, and registered dietitians.

OBJECTIVE: The primary aim of this study was to identify interventions used by pediatric health care providers in treatment of overweight children and adolescents to identify provider educational needs. A secondary aim was to examine the association of certain provider characteristics with recommended evaluation practices. STUDY DESIGN: A random sample of pediatricians, pediatric nurse practitioners, and registered dietitians (RDs) received questionnaires about their diet, activity, and medication recommendations for overweight patients and about referrals to specialists and programs. Results were examined for adherence to published recommendations and for associations with certain respondent characteristics. RESULTS: A total of 940 providers responded (response rate: 19%-33%). The majority recommended "changes in eating patterns" and "limitations of specific foods." Half or more used "low-fat diet" and "modest calorie restriction" in adolescents. Less than 15% used "very low-calorie diet." Fewer RDs recommended more restrictive diets. More than 60% of all groups followed recommended eating interventions for school-aged children and adolescents. More than 80% followed recommended physical activity interventions for all age groups. In each group, about 5% sometimes recommended prescription medication and herbal remedies for adolescents. None recommended surgery. Two thirds of pediatricians and pediatric nurse practitioners often referred to RDs. Approximately 20% referred to child/adolescent weight programs, but for 27% to 42%, these programs or pediatric obesity specialists were not available. No consistent associations between respondent characteristics and adherence to recommended interventions were identified. CONCLUSIONS: The providers generally promoted healthy eating and activity with minimal use of highly restrictive diets or medication to control weight.

Adolescent↗

PubMed2006

Medication adherence among adolescents in a school-based health center.

School-based health centers are an integral part of the health care delivery system for low-income children. Medication adherence for these patients may be challenging because the student is often responsible for bringing home the prescription and receiving the instructions. This study assesses medication fill, initiation, and adherence rates among adolescents in a school-based health center to identify major barriers to medication compliance. Students enrolled in a school-based health center, >or=10 years old, able to read and write English, and whose parent had provided consent for participation, were eligible for the study. Eligible students who received a prescription from the health center were invited to return to the clinic a week later to complete a questionnaire (with verbal assent). Primary outcome measures included medication fill rates, medication initiation rates, medication adherence rates, and reasons for nonadherence. Eighty-one students completed the questionnaire: 45 students (55.6%) filled their prescription. Of the students who filled their prescriptions, 75.6% reported always taking their medication at the appropriate time, 22.2% reported sometimes forgetting to take their medication, and 2.2% reported never taking the medication. However, many discrepancies were found between reported medication-taking behavior and the instructions provided to the student. Medication fill, initiation, and adherence rates among students receiving prescriptions for medications in school-based health centers are suboptimal. Interventions that address key identified barriers need to be developed and evaluated in order to achieve optimal fill and adherence rates.

Adolescent↗