Alexandra L. Dima

Asthma inhaler adherence determinants in adults: systematic review of observational data

Nonadherence to inhaled medication leads to poor asthma control and increased healthcare utilisation. Many studies exploring adherence determinants have been conducted, but summaries of the evidence are scarce. We performed a systematic review of observational research on determinants of asthma inhaler adherence among adults. We searched for articles in English reporting quantitative observational studies on inhaler adherence correlates among adults in developed countries, published in EMBASE, Medline, PsychInfo and PsychArticles in 1990–2014. Two coders independently assessed eligibility and extracted data, and assessed study quality. Results were summarised qualitatively into social and economic, and healthcare-, therapy-, condition- and patient-related factors. The 51 studies included mainly examined patient-related factors and found consistent links between adherence and stronger inhaler-necessity beliefs, and possibly older age. There was limited evidence on the relevance of other determinants, partly due to study heterogeneity regarding the types of determinants examined. Methodological quality varied considerably and studies performed generally poorly on their definitions of variables and measures, risk of bias, sample size and data analysis. A broader adoption of common methodological standards and health behaviour theories is needed before cumulative science on the determinants of adherence to asthma inhalers among adults can develop further. Major opportunities for strengthening evidence on determinants of nonadherence to asthma inhalers: methods and theory http://ow.ly/DY4vr

Advancing methodology in the study of HIV status disclosure: The importance of considering disclosure target and intent

Disclosure of HIV status has been the focus of three decades of research, which have revealed its complex relations to many behaviors involved in HIV prevention and treatment, and exposed its central role in managing the HIV epidemic. The causes and consequences of disclosure acts have recently been the subject of several theoretical models. Although it is acknowledged that individual disclosure events are part of a broader process of disclosing ones HIV status to an increasing number of people, this process has received less theoretical attention. In quantitative studies of disclosure, researchers have often implicitly assumed that disclosure is a single unidimensional process appropriately measured via the total number of ones disclosure acts. However, there is also evidence that disclosure may have different causes and consequences depending on the types of actors involved (e.g. family members, friends) and on the presence or absence of the disclosers intention, suggesting that the unidimensionality assumption may not hold. We quantitatively examined the dimensionality of voluntary and involuntary disclosure to different categories of actors, using data collected via structured interviews in the spring of 2010 from 158 people living with HIV in Kilimanjaro, Tanzania. For voluntary disclosure, nonparametric item response analyses identified two multi-category clusters, family and community, and two single-category dimensions, partner and children. Involuntary disclosure consisted of several single- or two-category dimensions. Correlation analyses between the resulting disclosure dimensions and stigma and social support revealed distinct relationships for each disclosure dimension. Our results suggest that treating disclosure as a unidimensional construct is a simplification of disclosure processes that may lead to incorrect conclusions about disclosure correlates. We therefore recommend examining disclosure acts jointly to identify sample-specific dimensions before examining causes and consequences of disclosure. We propose a methodology for investigating disclosure processes, and recommend its adoption in future disclosure studies.

Basic emotion profiles in healthy, chronic pain, depressed and PTSD individuals

OBJECTIVES To compare self-reports of five basic emotions across four samples: healthy, chronic pain, depressed and post-traumatic stress disorder (PTSD), and to investigate the extent to which basic emotion reports discriminate between individuals in healthy or clinical groups. METHODS In total, 439 participants took part in this study: healthy (n = 131), chronic pain (n = 220), depressed (n = 24) and PTSD (n = 64). The participants completed the trait version of the Basic Emotion Scale. Basic emotion profiles were compared both within each group and between the healthy group and each of the three other groups. Discriminant analysis was used to assess the extent to which basic emotions can be used to classify the participants as belonging to the healthy group or one of the clinical groups. RESULTS In the healthy group, happiness was experienced more than any other basic emotion. This was not found in the clinical groups. In comparison to the healthy participants, the chronic pain group experienced more fear, anger and sadness, the depressed group reported more sadness and the PTSD group experienced all of the negative emotions more frequently. Discriminant analysis revealed that happiness was the most important variable in determining whether an individual belonged to the healthy group or one of the clinical groups. Anger was found to further discriminate between depressed and chronic pain individuals. CONCLUSION The findings demonstrate that basic emotion profile analysis can provide a useful foundation for the exploration of emotional experience both within and between healthy and clinical groups. 

Dynamic pain-emotion relations in chronic pain: a theoretical review of moderation studies

Abstract Current developments in chronic pain research are changing the focus in the study of pain–emotion relations from the identification of general patterns to the study of dynamic and context-related interactions manifesting both within and between individuals. This shift towards understanding variation at both intra- and interpersonal levels has significant clinical implications for psychological adjustment to chronic pain conditions, and thus represents an important topic for both clinical and health psychology. This article reviews the existing theoretical explanations of these dynamics and their emerging empirical support, and suggests further areas of investigation. A literature search identified research on moderators of pain–emotion relations in chronic pain; existing theories were also examined from this perspective. A theoretical analysis revealed several important contributions, including the concepts of affect differentiation, generalised discrimination ability, resilience, vulnerability, coping, emotion regulation and desynchrony, which are described here together with the relevant empirical research and clinical implications. Important areas for development are the clarification of the common elements and opposing predictions and the empirical examination of mediating mechanisms. Several methodological issues are discussed. This review identifies a rich theoretical basis for research into pain–emotion moderation, and suggests that further examinations of such relationships might hold important clinical consequences.

“Lovely pie in the sky plans”: a qualitative study of clinicians’ perspectives on guidelines for managing low back pain in primary care in England

Study Design. A qualitative study in south-west England primary care. Objective. To clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians’ perspectives on the English National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. Summary of Background Data. Merely publishing clinical guidelines is known to be insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians’ perspectives on specific clinical guidelines can suggest ways to improve the relevance of guidelines for clinical practice. Methods. We conducted semi-structured interviews with 53 purposively sampled clinicians. Participants were 16 general practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21), or both (12). We used thematic analysis. Results. Official guidelines comprised just 1 of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organizational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology—“non-specific LBP”—unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services, and sparse commissioning of guideline-recommended treatments. Conclusion. The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring that guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for public sector patients. Level of Evidence: N/A.

Mapping the Asthma Care Process: Implications for Research and Practice

BACKGROUND Whether people with asthma gain and maintain control over their condition depends not only on the availability of effective drugs, but also on multiple patient and health care professional (HCP) behaviors. Research in asthma rarely considers how these behaviors interact with each other and drug effectiveness to determine health outcomes, which may limit real-life applicability of findings. OBJECTIVE The objective of this study was to develop a logic process model (Asthma Care Model; ACM) that explains how patient and HCP behaviors impact on the asthma care process. METHODS Within a European research project on asthma (ASTRO-LAB), we reviewed asthma care guidelines and empirical literature, and conducted qualitative interviews with patients and HCPs. Findings were discussed with the project team and respiratory care experts and integrated in a causal model. RESULTS The model outlines a causal sequence of treatment events, from diagnosis and assessment to treatment prescription, drug exposure, and health outcomes. The relationships between these components are moderated by patient behaviors (medication adherence, symptom monitoring, managing triggers, and exacerbations) and HCP behaviors (medical care and self-management support). Modifiable and nonmodifiable behavioral determinants influence the behaviors of patients and HCPs. The model is dynamic as it includes feedback loops of behavioral and clinical outcomes, which influence future patient and HCP decision making. Key evidence for each relationship is summarized to derive research priorities and clinical recommendations. CONCLUSIONS The ACM model is of interest to both researchers and practitioners, and intended as a first version (ACM-v1) of a common framework for generating and translating research evidence in asthma care.

Assessing treatment-as-usual provided to control groups in adherence trials: Exploring the use of an open-ended questionnaire for identifying behaviour change techniques

Objective: Reporting guidelines call for descriptions of control group support in equal detail as for interventions. However, how to assess the active content (behaviour change techniques (BCTs)) of treatment-as-usual (TAU) delivered to control groups in trials remains unclear. The objective of this study is to pre-test a method of assessing TAU in a multicentre cost-effectiveness trial of an HIV-treatment adherence intervention. Design: HIV-nurses (N = 21) completed a semi-structured open-ended questionnaire enquiring about TAU adherence counselling. Two coders independently coded BCTs. Main outcome measures: Completeness and clarity of nurse responses, inter-coder reliabilities and the type of BCTs reported were examined. Results: The clarity and completeness of nurse responses were adequate. Twenty-three of the 26 identified BCTs could be reliably coded (mean κ = .79; mean agreement rate = 96%) and three BCTs scored below κ = .60. Total number of BCTs reported per nurse ranged between 7 and 19 (M = 13.86, SD = 3.35). Conclusions: This study suggests that the TAU open-ended questionnaire is a feasible and reliable tool to capture active content of support provided to control participants in a multicentre adherence intervention trial. Considerable variability in the number of BCTs provided to control patients was observed, illustrating the importance of reliably collecting and accurately reporting control group support.

Assessment of the safety of long-acting β2-agonists in routine asthma care: the ASTRO-LAB protocol

ASTRO-LAB is funded by the European Commission through the Seventh Framework Program (FP7-Grant Agreement n° 282 593) and gathers seven partners in a Consortium: Universite Claude Bernard Lyon 1, University of Nottingham, Kappa Sante SAS, Cegedim Strategic Data Medical Research Limited, University of Amsterdam, Consortio Mar Parc de Salut de Barcelona and Lyon Ingenierie Projets.

Inhaled Corticosteroid Adherence Patterns in a Longitudinal Asthma Cohort

BACKGROUND Electronic prescribing records can enable exploration of medication adherence, but analysis decisions may influence estimates and require alignment to new consensus-based definitions. OBJECTIVE To compare different computations of inhaled corticosteroid (ICS) implementation in a primary care asthma population initiating ICS therapy when assessed within episodes of persistent use, and examine longitudinal variation in implementation. METHODS A historical cohort study was conducted on UKs Optimum Patient Care Research Database. Eligible patients had physician-diagnosed asthma, initiated ICS therapy, and had 3 or more years of continuous registration. ICS treatment episodes were constructed on the basis of 3 definitions, permitting 30-, 90-, and 182-day gaps between prescriptions. Implementation was estimated using 2 continuous medication availability (CMA I and II) definitions to explore effects of carryover of previous prescriptions in 4 observation windows: 6, 8, 12, and 24 months. Impact of methodology was assessed by descriptive statistics, linear mixed models, and measures of agreement. RESULTS A total of 13,922 eligible patients (mean age, 39.9 years; 48.7% men) were identified. For CMA I, permitting a 90-day gap, mean ICS implementation for the 2-year period was 89.3% (±16.0%; range, 14.4%-100%). Sensitivity analyses with 30- and 182-day gaps resulted in increased (97.0% ± 7.2%) and decreased (81.1% ± 21.6%) estimates. CMA II produced estimates with varying concordance (0.69-0.87). Substantial variance was found between and within patients (intraclass coefficient, 0.30-0.36). CONCLUSIONS Different analysis choices resulted in substantial variation in implementation estimates, highlighting the need for transparent and clinically relevant methododology. Distinguishing between (non)persistence and implementation is important in clinical practice, and may require different interventions in routine consultations.

Measuring medication adherence in asthma : Development of a novel self-report tool

Objective: This study presents the development and validation of MIS-A (Medication Intake Survey-Asthma), a new self-report instrument measuring key adherence properties during long-term asthma treatment. Design: Within a longitudinal asthma cohort study in France and the United Kingdom, adult patients and caregivers of children responded to computer-assisted telephone interviews. Main outcome measures: Scores for distinct adherence properties (taking adherence, correct dosing, therapeutic coverage, drug holidays, overuse) and composite measures were computed for several time intervals. We examined distributions, longitudinal variation, associations between adherence scores and concordance with adherence calculated from medication prescribing or dispensing records. Results: Nine hundred and two participants reported on adherence to 4481 medications on 4140 occasions. About 59.47 and 70.36% revealed < 100% taking adherence in the last week and month; 42.76% had a drug holiday of > 1 week in the last 4 months. Adherence varied within patients during the follow-up (intra-class correlation = . 41–.71). Correlations between adherence scores were moderate to strong (ρ = .51–.85, p ≤ .001), except medication overuse (ρ = .04–.19, p ≤.05). Four-month taking adherence was associated with dispensing adherence, but not with prescribing adherence (ρ = .33, p < .001; and .12, p = .26). Conclusion: MIS-A is a promising, easy-to-use self-report tool that can capture accurately different adherence properties over a long time period.