Effectiveness of Community Based Interventions for Children with Asthma

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Effectiveness of Community Based Interventions
for Children with Asthma

• Noreen M. Clark, PhD
• Myron E. Wegman Distinguished University
  Professor
• Director, Center for Managing Chronic Disease
• University of Michigan

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Improving Adherence in Pediatric Asthma Where
to from Here?

• Cynthia Rand, Ph.D.
• Johns Hopkins School of Medicine

Merck Childhood Asthma Network State of Childhood
Asthma and Future Directions Strategies for
Implementing Best Practices ,December 13-14, 2006
Washington DC
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25 Years Pediatric Adherence ResearchWhat
Weve Learned

• Rates of pediatric nonadherence with therapy are
  comparable to adult nonadherence (i.e.50)

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Percent of Children with Acute Severe Asthma
Filling Systemic Corticosteroid Prescriptions
Cooper W. Arch Pediatr Adolesc Med 20011551111
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25 Years Pediatric Adherence ResearchWhat
Weve Learned

• Pediatric self-reports of good adherence are as
  unreliable as adult reports
• Just as adult depression influences adherence
  with therapy, maternal depression influences
  pediatric adherence with asthma therapy
• Maternal health beliefs about asthma and
  controller therapy are strongly associated with
  adherence

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Parent/PCP Concordance on ICS Use by Maternal
Beliefs Should Children Take Asthma Medicines
Daily Even When They Dont Have Symptoms?
P0.005
Maternal Responses

N319
Riekert KA, et al. Caregiver-Physician Medication
Concordance and Under-Treatment of Asthma Among
Inner-City Children. Pediatrics. 2003
Mar111(3)E214-20
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25 Years Pediatric Adherence ResearchWhat
Weve Learned

• Family structure and routines are predictive of
  better adherence
• Pediatrician communication skills can influence
  family/pediatric adherence
• While asthma education can significantly improve
  pediatric asthma adherence, improvements are
  often modest and transitory

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Improving Patient Adherence with Chronic
Therapies What Does the Research Show?

• Changing adherence behavior is difficult
• Education in not enough
• Successful interventions are usually
  multi-factorial
• Recent intervention strategies that have shown
  some promise include
• improved patient-provider communication
• simplifying therapy
• interventions to improve motivation
• monitoring and feedback of adherence
• Shared-decision-making

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Improving Patient Adherence with Chronic
Therapies What Does the Research Show?

• Intensive provider/patient education and
  counseling strategies can be costly, complex and
  difficult to broadly implement
• New strategies to promote adherence are needed
  that are broadly generalizable, low-cost and
  sustainable

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• Compliance- following doctors orders
• Adherence-the extent to which a persons behavior
  corresponds with recommendations from a health
  care provider
• Concordance-shared decision-making a coming to an
  agreement that respects the patients beliefs and
  wishes

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Where to from Here?

• Considering the whole patient and family real
  world barriers to pediatric asthma treatment
  persistence and adherence
• Improving pediatric adherence with asthma
  therapy Lessons from the most successful health
  behavior intervention ever conducted

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Not Sure of Difference Between Different Asthma
Meds
Worried Child Will Become Addicted
Mom is dealing With depression
Teenager is Embarrassed About using Inhaler in
front of friends
Worries about Giving her Child medicine everyday
Chronic Disease
Effective Disease Management
Family Schodule Is Chaotic
Effective Therapies
Patient Adherence
Child Has no Symptoms Right Now
Child Splits Time Between Mom and Dads Houses
Pediatric Adherence with Asthma Therapy Ideal
and Real World
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Lessons learned from tobacco control initiatives

• Clear, unambiguous and reiterated public health
  messages can change health behavior
• Social institutions and public opinion are
  powerful agents for health behavior change
• Community and social institutions supported
  nonsmoking while penalizing and marginalizing
  smoking
• Simple, directive advice of health care providers
  can change health behaviors
• While intensive, high cost interventions can
  achieve moderate levels of change in select
  populations, low-cost, low-intensity
  interventions can achieve small changes in large
  populations.
• Even small health behavior changes over large
  populations can yield significant health benefits

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Adherence promotion from a public health framework

• Enhance use of the media and visible public
  health forums to promote, remind and reinforce
  adherence with chronic therapies
• Partner with social and community organizations
  to facilitate and support adherence with chronic
  therapies (e.g. schools, churches, workplaces,
  grocery stores, etc.) including resource to
  address barriers to adherence (e.g. cost)
• Incorporate simple adherence assessment and
  promotion into all health encounters, ideally
  with EMR and EPR support
• Explore the potential of technology-based support
  for adherence promotion including web-based,
  email, IVR software.
• Consider low-cost, large scale interventions
  designed to achieve small changes in adherence
  over large populations

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Summary

• Why should we consider asthma therapies in the
  context of the whole patient and family?
• Because even therapies with high efficacy will
  not be used if they dont fit a familys personal
  capacities, goals, and beliefs.
• What can we learn from the success of smoking
  cessation efforts in the US?
• While health behavior change is difficult, clear
  public health messages, social and institutional
  support, and simple, low-cost, broad-based
  interventions may have the potential to improve
  pediatric adherence with asthma therapies

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Recommendations

• Develop innovative strategies to integrate
  adherence promotion and support into relevant
  health care delivery systems
• Develop provider, pharmacy and family support
  programs that reinforce and support adherence
  with therapy

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Recommendations

• Integrate childrens adherence support into
  school-based asthma education and medical care
  via school-based clinics

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Effectiveness of Community Based Interventions
for Children with Asthma

• Noreen M. Clark, PhD
• Myron E. Wegman Distinguished University
  Professor
• Director, Center for Managing Chronic Disease
• University of Michigan