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Children spend the majority of their time indoors, and a substantial portion of this time in the school environment. Air pollution has been shown to adversely impact lung development and has effects that extend beyond respiratory health. The goal of this study was to evaluate the indoor environment in public schools in the context of an ongoing urban renovation program to investigate the impact of school building renovation and replacement on indoor air quality. Indoor air quality (CO2, PM2.5, CO, and temperature) was assessed for two weeks during fall, winter, and spring seasons in 29 urban public schools between December 2015 and March 2020. Seven schools had pre- and post-renovation data available. Linear mixed models were used to examine changes in air quality outcomes by renovation status in the seven schools with pre- and post-renovation data. Prior to renovation, indoor CO measurements were within World Health Organization (WHO) guidelines, and indoor PM2.5 measurements rarely exceeded them. Within the seven schools with pre- and post-renovation data, over 30% of indoor CO2 measurements and over 50% of indoor temperatures exceeded recommended guidelines from the American Society of Heating, Refrigerating, and Air Conditioning Engineers. Following renovation, 10% of indoor CO2 measurements and 28% of indoor temperatures fell outside of the recommended ranges. Linear mixed models showed significant improvement in CO2, indoor PM2.5, and CO following school renovation. Even among schools that generally met recommendations on key guidelines, school renovation improved the indoor air quality. Our findings suggest that school renovation may benefit communities of children, particularly those in low-income areas with aging school infrastructure, through improvements in the indoor environment.

BackgroundThe purpose of this study was to explore the association between perceived social support and COPD outcomes and to determine whether the associations are mediated by depressive symptoms.MethodsSubjects with COPD who were enrolled as part of SPIROMICS were included in this analysis. Questionnaires relating to quality of life, symptom burden, and functional status were administered at annual clinic visits for over a 3 year period. In both cross-sectional and longitudinal analyses, we examined the association of social support as measured by the FACIT-F with COPD outcomes. Cross sectional analyses used multivariable linear or logistic regression, adjusting for covariates. For longitudinal analyses, generalized linear mixed models with random intercepts were used. Models were adjusted with and without depressive symptoms and mediation analyses performed.ResultsOf the 1831 subjects with COPD, 1779 completed the FACIT- F questionnaire. In adjusted cross-sectional analysis without depressive symptoms, higher perceived social support was associated with better quality of life, well-being, 6 minute walk distance, and less dyspnea. When also adjusting for depressive symptoms, all associations between social support and COPD outcomes were attenuated and no longer statistically significant. Mediation analysis suggested that depressive symptoms explained the majority (> = 85%) of the association between social support and measured COPD outcomes. Results of the longitudinal analysis were consistent with the cross-sectional analyses. There was no association between social support and odds of exacerbations.ConclusionHigher social support was associated with better COPD outcomes across several measures of morbidity including quality of life, respiratory symptoms, and functional status. In addition, these associations were largely attenuated when accounting for depressive symptoms suggesting that the beneficial association of social support with COPD outcomes may be largely mediated by the association between social support and depression.Trial registrationSPIROMICS was approved by Institutional Review Boards at each center and all participants provided written informed consent (clinicaltrials.gov:NCT01969344).

Introduction: Educational campaigns have the potential to inform at risk populations about key issues relevant to lung health and to facilitate active engagement promoting healthy behaviors and risk prevention. We developed a community-based educational campaign called the Lung Health Ambassador Program (LHAP) with a goal of engaging youth and empowering them to be advocates for pulmonary health in their community. Objective: To evaluate the process outcomes and feasibility of the inaugural LHAP (2018–2019 academic year), with a specific aim to impact tobacco policy in the state of Maryland. Methods: Outcomes regarding feasibility included assessment of number of schools reached, number of students and healthcare professionals participating, and types of projects developed by participating students to impact modifiable risk factors for lung health. The courses for the LHAP were five 1 h sessions implemented at days and times identified by the community. The topics of the LHAP focused on lung anatomy, pulmonary diseases affecting school aged youth, tobacco use and prevalence, and air pollution (both indoor and outdoor). The fifth class discussed ways in which the students could impact lung health (e.g., policy and advocacy) and mitigate pulmonary disparities. Main Results: The LHAP was implemented at two elementary/middle schools, one high school, and two recreation centers within an urban metropolitan region. A total of 268 youths participated in the LHAP (age ranging from 11 to 18), whereby 72 (26.9%) were Hispanic/Latino and 110 (41.0%) were African American. Of the participating students, 240 wrote letters to local politicians to advocate for policies that would raise the legal age of acquiring tobacco products to 21. As for healthcare professionals, 18 academic faculty members participated in implementing the LHAP: 8 physicians and faculty staff and 10 nurses. Conclusions: The LHAP is a community-based program that provides education and training in advocacy with a goal of teaching about and, ultimately, reducing respiratory health disparities. The results from the first year demonstrate that the program is feasible, with success demonstrated in completing educational modules and engaging students. Next steps will include strategies to ensure sustainability and scalability to increase the reach of this program.

As evidence emerged supporting noninvasive strategies for coronavirus disease 2019 (COVID-19)–related respiratory distress, we implemented a noninvasive COVID-19 respiratory protocol (NCRP) that encouraged high-flow nasal cannula (HFNC) and self-proning across our healthcare system. To assess safety, we conducted a retrospective chart review evaluating mortality and other patient safety outcomes after implementation of the NCRP protocol (April 3, 2020, to April 15, 2020) for adult patients hospitalized with COVID-19, compared with preimplementation outcomes (March 15, 2020, to April 2, 2020). During the study, there were 469 COVID-19 admissions. Fewer patients underwent intubation after implementation (10.7% [23 of 215]), compared with before implementation (25.2% [64 of 254]) (P < .01). Overall, 26.2% of patients died (24% before implementation vs 28.8% after implementation; P = .14). In patients without a do not resuscitate/do not intubate order prior to admission, mortality was 21.8% before implementation vs 21.9% after implementation. Overall, we found no significant increase in mortality following implementation of a noninvasive respiratory protocol that decreased intubations in patients with COVID-19.

IMPORTANCE: Asthma is the most common chronic childhood disease, with Black children experiencing worse morbidity and mortality. It is important to evaluate the effectiveness of efficacious interventions in community settings that have the greatest likelihood of serving at-risk families. OBJECTIVE: To evaluate the effectiveness of a multilevel home- and school (Head Start)–based asthma educational program compared with a Head Start–based asthma educational program alone in improving asthma outcomes in children. DESIGN, SETTING, AND PARTICIPANT: This randomized clinical trial included 398 children with asthma enrolled in Head Start preschool programs in Baltimore, Maryland, and their primary caregivers. Participants were recruited from April 1, 2011, to November 31, 2016, with final data collection ending December 31, 2017. Data were analyzed from March 18 to August 30, 2018. INTERVENTIONS: Asthma Basic Care (ABC) family education combined with Head Start asthma education compared with Head Start asthma education alone. MAIN OUTCOMES AND MEASURES: Asthma control as measured by the Test for Respiratory and Asthma Control in Kids (TRACK) score. RESULTS: Among the 398 children included in the analysis (247 boys [62.1%]; mean [SD] age, 4.2 [0.7] years), the ABC plus Head Start program improved asthma control (β = 6.26; 95% CI, 1.77 to 10.75; P

Objective To evaluate whether engagement and affective communication among adolescents and young adults (AYAs) with chronic kidney disease (CKD), caregivers, and pediatric nephrology providers during outpatient clinic visits predicts antihypertensive medication adherence. Methods AYAs (n = 60, M age = 15.4 years, SD = 2.7, 40% female, 43% African American/Black) and caregivers (n = 60, 73% female) attended audio-recorded clinic visits with pediatric nephrologists (n = 12, 75% female). Recordings were analyzed using global affect ratings of the Roter Interactional Analysis System. Antihypertensive medication adherence was monitored electronically before and after clinic visits. A linear regression model evaluated associations between affect ratings and post-visit adherence. Results AYAs took 84% of doses (SD = 20%) pre-visit and 82% of doses (SD = 24%) post-visit. Higher AYA engagement (β = 0.03, p = .01) and the absence of provider negative affect (β=-0.15, p = .04) were associated with higher post-visit adherence, controlling for pre-visit adherence, AYA sex, age, and race, and clustered by provider. Conclusions Post-visit adherence was higher when AYAs were rated as more engaged and providers as less negative. Practice Implications AYAs with lower engagement may benefit from further adherence assessment. Communication strategies designed to more actively engage AYAs in their care and diminish provider conveyance of negative affect during clinic visits may positively influence adherence among AYAs with CKD.

Background Participant retention is a major challenge in clinical research, especially in studies with multiple, longitudinal research assessments. Despite the importance of retention methods, there is little empirical research on how cohort retention efforts are perceived by study participants. Research Question To evaluate the association between the number of attempts undertaken to contact participants for research assessments in a longitudinal cohort study and participants' feeling of being bothered regarding such contact attempts. Study Design and Methods Secondary analysis of 315 ARDS survivors participating in a prospective study using comprehensive strategies for participant follow-up at 6 and 12 months that achieved > 95% participant retention. After completing a 242-question research assessment lasting 20 to 40 min, participants were surveyed for feedback. Results At 6 and 12 months, only 5% and 8% of participants, respectively, reported being bothered "more than a little bit" by the study contact attempts, with an OR of 1.06 (95% CI, 1.02-1.10) for each contact attempt. Participants' mental health symptoms at follow-up assessment were not associated with reports of being bothered. Interpretation Comprehensive cohort retention efforts can achieve > 95% retention rates in a national longitudinal study, with most participants reporting little or no bother by contact attempts. Despite a high frequency of mental health symptoms in this population, such symptoms were not associated with participant feedback regarding contact attempts. Careful training of research staff may be important in achieving such results.

BACKGROUND: Sarcoidosis, one of the most common interstitial lung diseases, has significant health disparities. Approximately 50% of individuals affected with sarcoidosis will undergo spontaneous remission, but those who do not undergo remission often require long-term or lifelong treatment to prevent disease progression. We sought to assess the association between medication adherence and clinical outcomes in sarcoidosis. METHODS: Adult patients in the Johns Hopkins Sarcoidosis Clinic diagnosed with pulmonary sarcoidosis on treatment were eligible for enrollment. Questionnaires were administered to assess medication adherence, health-related quality of life (HRQoL), health-care utilization, and sociodemographic information. Clinical information was abstracted from medical charts including lung function, disease duration, comorbidities, and sarcoidosis organ involvement. RESULTS: A total of 117 participants were enrolled (57% women; 55% black; median age, 57 years). Within the cohort, 66% of individuals reported at least one nonadherent behavior. Higher medication adherence was associated with better HRQoL (P

Background Low inhaled corticosteroid (ICS) adherence is associated with increased asthma burden. This relationship is likely bidirectional, and may vary across adherence stages (initiation, implementation, and persistence). Studies rarely examine reciprocal influences. Objective To investigate the relationship between ICS implementation and asthma-related outcomes over 2 years, considering bidirectionality and temporal sequence. Methods Primary care records (1987-2012) from the Optimum Patient Care Research Database, United Kingdom, were used. Eligible patients were 6 years or older and had 3 or more years of continuous registration starting 1 year before ICS initiation (index date), physician-diagnosed asthma, 2 or more ICS and/or short-acting β-agonist prescriptions each follow-up year, and no long-acting β-agonists, leukotriene receptor antagonists, or maintenance oral corticosteroids in the preceding year. ICS implementation (percentage of days covered) and risk domain asthma control (RDAC; no asthma-related hospitalizations, emergency visits, or outpatient visits and no oral corticosteroid or antibiotic prescriptions with evidence of respiratory review) were estimated for each prescription interval (period between 2 successive prescriptions). Multilevel analyses modeled bidirectional relationships between ICS implementation and RDAC (and its components), controlling for sociodemographic and clinical characteristics. Results In prescription data from 10,472 patients, ICS implementation in the preceding interval did not predict RDAC, but was weakly positively associated with simultaneous RDAC. Being male, non–current smoker, without chronic obstructive pulmonary disease diagnosis, and with fewer than 4 comorbidities significantly increased odds of RDAC. Asthma-related antibiotics and outpatient visits in the same interval and short-acting β-agonist overuse in the preceding and same interval predicted lower ICS implementation. Conclusions Patients may adapt their ICS use to their current needs without this impacting later RDAC.

BackgroundOn-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial.MethodsWe conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions.ResultsQualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients.ConclusionsSome housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care.

OBJECTIVE: To investigate longitudinal associations of health beliefs, which included self-efficacy, outcome expectancies, and perceived barriers, and demographic risk factors (i.e., age, gender, race, and family income) with antihypertensive medication adherence in adolescents with chronic kidney disease (CKD) over 24 months. METHOD: The sample included 114 adolescents (M age = 15.03 years, SD = 2.44) diagnosed with CKD. Adolescents reported their self-efficacy for taking medications, medication outcome expectancies, and barriers to adherence at baseline and 12 and 24 months after baseline. Antihypertensive medication adherence was assessed via electronic monitoring for 2 weeks at baseline and 6, 12, 18, and 24 months after baseline. RESULTS: Adherence increased and then decreased over the 2-year study period (inverted U-shape). Self-efficacy, outcome expectancies, and barriers did not change over time. Older adolescent age, female gender, African American race

Beliefs about medication have been associated with adherence in other diseases but there are no existing disease-specific medication beliefs questionnaires for CF. This mixed-methods validated the Cystic Fibrosis Medication Belief Questionnaire (CF-MBQ), based on social cognitive theory.Based on previous research, items were developed for five domains: motivation, self-efficacy, perceived importance, and decisional balance to take or miss medications. Cognitive interviews were conducted with 15 adult patients with CF to refine item development. 128 patients with CF completed an online survey and objective medication adherence was measured using pharmacy refill data.The five subscales demonstrated strong psychometric properties, with adequate-to-good internal consistency scores. More importantly, each domain demonstrated construct validity with adherence.These theoretically-derived measures may be important for clinical purposes to provide guidance on appropriate interventions to improve adherence and for research to provide enhanced understanding on patient determinants of medication adherence.

OBJECTIVE: To compare the relative quantity of talk between providers, caregivers, and adolescents and young adults (AYAs) with chronic kidney disease (CKD) and how communication differs by age. METHODS: During nephrology clinic visits, conversations between AYAs with CKD (N = 99, ages 11 –20, median = 15), their caregivers, and providers (N=19) were audiotaped and coded using the Roter Interaction Analysis System. Linear mixed models tested AYA age differences in talk frequency by AYAs, caregivers, and providers. Post-hoc analyses tested differences in talk using AYA age groups. RESULTS: During clinic visits, providers spoke the most (63.7%), and caregivers spoke more (22.6%) than AYAs (13.7%). Overall talk differed by AYA age in AYAs (p < 0.001) and caregivers (p

Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy that causes significant morbidity and mortality related to chronic hemolytic anemia, vaso-occlusion, and resultant end-organ damage. Tobacco smoke exposure (TSE) through secondhand smoke exposure in people with SCD of all ages and through primary smoking in adolescents and adults is associated with significantly increased morbidity, with increased rates of emergency department visits and hospitalizations for painful vaso-occlusive crises and acute chest syndrome (ACS). Secondhand smoke is also associated with pulmonary function abnormalities in children with SCD who are already at risk for pulmonary function abnormalities on the basis of SCD. TSE is emerging as one of the few modifiable risk factors of SCD. This review discusses the current state of the evidence with respect to TSE and SCD morbidity, discusses potential mechanisms, and highlights current gaps in the evidence and future research directions.

Intensive care unit (ICU) patients' expected post-discharge outcomes are rarely discussed in family meetings despite this information being centrally important to patients and their families.To characterize intensivist-identified barriers and facilitators to discussing post-discharge outcomes with surrogates of ICU patients.Qualitative study conducted via one-on-one, semistructured telephone interviews with 23 intensivists from 20 hospitals with accreditation council for graduate medical education-accredited critical care medicine programs in 16 states. A limited application of grounded theory methods was used to code transcribed interviews and identify themes and illustrative quotes.Intensivists reported tension between their professional responsibility to discuss likely functional outcomes versus uncertainty about their ability to predict those outcomes for an individual patient. They cited three main barriers as limiting their ability to conduct conversations about post-discharge outcomes with ICU surrogates: (1) incorrectly optimistic expectations for recovery among ICU surrogates, (2) having little or no contact with their patients after ICU discharge, and (3) minimal confidence applying existing outcomes research to individual patients. Despite these barriers, experience talking to ICU surrogates, seeing ICU survivors in the outpatient setting, and trusted research on functional outcomes were identified as important facilitators to discussing likely patient outcomes with surrogates. Intensivists generally welcomed questions from surrogates about post-discharge outcomes as opportunities to initiate conversations about prognosis and patient values.In this sample of intensivists from 20 academic hospitals, experience conducting conversations with surrogates and interactions with ICU survivors as outpatients were identified as facilitating discussion of expected post-discharge outcomes while optimistic surrogate expectations and prognostic uncertainty were barriers. There was tension between self-perceived ability to prognosticate and belief in a professional obligation to discuss patient outcomes.

OBJECTIVE: To identify barriers and motivators for reducing secondhand smoke exposure (SHSe) for families of African-American, low-income, urban children.METHOD: Audiotaped intervention sessions of 52 African-American caregivers of Head Start children who reported being a smoker and/or had at least one smoker in the home were randomly sampled from a larger trial examining the effectiveness of a motivational-interviewing intervention in reducing child's SHSe. Counseling sessions were qualitatively coded to identify barriers and motivators to implementing a home smoking ban or quitting smoking.RESULTS: African-American families identified several themes that were either or both barriers and motivators for SHSe reduction, including: asking others not to smoke, other family living in the home, neighborhood safety, absence of childcare, cost/availability of cessation tools, physician support and prevention of health problems.DISCUSSION: Urban, low-income African-American families face numerous barriers to reducing SHSe. Families were able to identify many motivators for reducing SHSe, suggesting an awareness of the importance for SHSe reduction but uncertainty in their confidence to change behaviors. Counseling should include tailoring to be most effective in supporting health behavior change. Greater emphasis on motivators is needed, such as low-cost/free cessation tools, engagement from physicians and greater involvement of extended family members.

Introduction This study determines if expenditures associated with implementing a combined motivational interviewing (MI) and Head Start-level education program (MI+Education), as compared to education alone, yield cost savings to society. Methods Post hoc cost analyses were applied to a randomized controlled-trial of MI among predominantly African American, low-income caregivers of 330 Baltimore City Head Start students who reside with a smoker. The primary outcome was the cost savings of MI+Education from averted direct secondhand smoke exposure (SHSe)-related acute healthcare events and inferred indirect costs (work days lost, transportation and reduction in cigarettes smoked). The net direction of savings was defined by the sum of averted direct and indirect costs of the MI+Education intervention at 3, 6 and 12 months, benchmarked against the Education alone cohort at the equivalent time periods. Results The costs saved by the MI+Education intervention, relative to Education alone, resulted in savings at solely the 12-month follow-up time point. Significant savings were appreciated from averted emergency department (ED) visits at 12 months ($4410; 95% simulation interval [SI]: $2241, $6626) for the MI+Education group. The total savings at 12 months ($2274; 95% SI: -3916, $8442) could not overcome additional program costs of implementing MI to Head Start-level education ($13 695; 95% SI: $11 250, $16 034). Conclusions This study is the first to examine the cost of either intervention on SHSe-attributed pediatric healthcare costs from a population level relevant for federal and community decision makers. Intervention costs could not be offset by short-term savings but a trend towards positive savings was appreciated 1 year after implementation. Implications Behavioral interventions are effective in reducing SHSe in children. However, many of these interventions are not implemented in community settings due to lack of resources and money. Behavioral strategies may be a cost-saving addition to the national initiatives to create smoke-free home environments. The long-term benefits of MI, as evidenced from cost savings from averted ED visits, appeared to show MI+Education to be a robust long-term strategy. The decrease of acute healthcare services at 12 months may be informative for policy decision makers seeking to allocate limited resources to reduce the usage of costly ED services and hospital readmissions.

Adequate medication adherence is key for optimal benefit of pharmacological treatments. A wealth of research has been conducted to understand and identify opportunities to intervene to improve medication adherence, but variations in adherence definitions within prior research have led to ambiguity in study findings. The lack of a standard taxonomy hinders the development of cumulative science in adherence research. This article reviews the newly established Ascertaining Barriers to Compliance (ABC) taxonomy for medication adherence with a particular focus on its relevance and applicability within the context of asthma and chronic obstructive pulmonary disease management. Building on traditional definitions and concepts within medication adherence, the ABC taxonomy considers the temporal sequence of steps a patient must undertake to be defined as " adherent to treatment": (A) initiation, (B) implementation, and (C) persistence. We explain the clinical and research relevance of differentiating between these phases, point to differences in its applicability in observational and experimental research, review strengths and limitations of available measures, and highlight recent findings on specific determinants of these behaviors. Finally, we provide recommendations for research and practice with a view to supporting and sign posting opportunities to improve future respiratory medication adherence and associated research. (C) 2016 The Authors. Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma & Immunology. This is an open access article under the CC BY-NC-ND license.

The impact of caring for children with deglutition disorders is poorly understood and tools to measure the unique concerns of these caregivers are lacking. The aims of this investigation were to develop and validate The Feeding/Swallowing Impact Survey (FS-IS) as an instrument designed to measure and improve understanding of caregiver issues. Demographic, economic, and dysphagic data were provided by the primary caregivers of 164 children (median age: 14 months, male: 78, female: 86) presenting for initial outpatient feeding/swallowing evaluations. Caregivers completed the PEDS-QL™ Family Impact Module (PEDS-QL™ FIM) and the FS-IS. A principal component analysis was conducted on the FS-IS to identify appropriate subscales. Concurrent validity was assessed by examining correlations between the FS-IS and PEDS-QL™ FIM. Caring for children with feeding/swallowing problems adversely impacted the Health-Related Quality of Life (HRQoL) of their caregivers. The FS-IS had a strong 3-factor solution to indicate 3 subscales: Daily Activities, Worry, and Feeding Difficulties. All three sub-scales and total score of the FS-IS correlated with PEDS-QL™ FIM. The FS-IS was validated as an instrument that may help clinicians detect specific factors that influence caregiver HRQoL, identify caregivers who might benefit from additional support, and ultimately improve the care of their children with feeding/swallowing disorders.

People with chronic medical conditions are at increased risk for depression and depressive symptoms (Clarke & Currie, 2009). This poses a threat to disease management and symptom control, with evidence from a range of chronic conditions spanning pediatrics through adulthood demonstrating that elevated depressive symptoms increase the risk for nonadherence approximately two-to threefold (DiMatteo Lepper, & Croghan, 2000; Grenard et al., 2011). Specific symptoms of depression, such as negative mood, low self-esteem, feelings of ineffectiveness, deficits in memory or energy, and more perceived barriers to adherence, may detract from adherence (Katon & Ciechanowski, 2002; McGrady & Hood, 2010). Ultimately, the association between depression and poor adherence translates to increases in disease symptoms, medical costs, morbidity, and mortality (Barth, Schumacher, & Herrmann-Lingen, 2004; Katon & Ciechanowski, 2002). The link between depressive symptoms and treatment adherence is well established, yet the mechanisms of this association are not well understood. Clarifying the processes by which depressive symptoms influence adherence would provide valuable direction for interventions to buffer the negative impact of depressive symptoms and ultimately improve health outcomes. Negative beliefs about prescribed medications (e.g., low self-efficacy to take medications, expectation of medications having null or negative outcomes, low motivation or intention to take medications) are possible mechanisms by which depressive symptoms could impede adherence. It is plausible that individuals’ depressive symptoms could influence their medication beliefs to be more negative, which may reduce the likelihood of adhering to prescribed medications. Individuals’ beliefs about medications are related to medication adherence. In a recent meta-analysis, Horne and colleagues (2013) reported that higher perceived need for treatment and fewer perceived concerns about treatments are significantly associated with better adherence. This holds across many conditions: Negative beliefs about treatments or medications have demonstrated associations with poorer adherence among individuals with HIV (Barclay et al., 2007), diabetes (Gherman et al., 2011), sleep apnea (Olsen, Smith, Oei, & Douglas, 2008), hypertension (Quine, Steadman, Thompson, & Rutter, 2012), and those recovering from stroke (Robinson-Smith, Johnston, & Allen, 2000) and chronic back pain (Glattacker, Heyduck, & Meffert, 2013). Studies evaluating medication beliefs as a potential mechanism linking depression and adherence have focused almost exclusively on one specific belief, self-efficacy; results indicate that medication self-efficacy mediates the links between depression and medication adherence for hypertension (Schoenthaler, Ogedegbe, & Allegrante, 2009) and HIV (Cha, Erlen, Kim, Sereika, & Caruthers, 2008) and between depression and glycemic control in Type 2 diabetes (Cherrington, Wallston, & Rothman, 2010). Few studies have examined the roles that other medication beliefs aside from self-efficacy play in the link between depressive symptoms and medication adherence. One exception demonstrated that not only lower self-efficacy but also more perceived barriers to taking medications were mediators of the indirect link between depressive symptoms and self-reported adherence in adults with diabetes (Chao, Nau, Aikens, & Taylor, 2005). More research examining a broader range of medication beliefs, including motivation, perceived importance, and outcome expectancies related to taking medications, is needed to fully understand the cognitive mechanisms by which depressive symptoms relate to adherence. Understanding the role that a comprehensive set of relevant medication beliefs plays in depressive symptoms and medication adherence has the potential to inform and guide clinical interventions to reduce depressive symptoms, support adaptive health-promoting beliefs, and facilitate optimal disease management. Cystic fibrosis (CF) is a chronic, progressive, obstructive lung disease with a complicated and demanding treatment regimen that includes multiple medications, nutritional guidelines, and chest physiotherapy, and can take several hours a day to complete (Sawicki, Sellers, & Robinson, 2009). In 1986, the median life expectancy was 27 years and less than 29% of individuals with CF were ≥18 years old in the United States, but with advances in drug therapies, this has changed dramatically (Cystic Fibrosis Foundation, 2013). In 2012, 49% of individuals with CF were adults and the median life expectancy was 41 years (Cystic Fibrosis Foundation, 2013). As adolescents and adults now account for over half of the CF population, there is growing attention to their health status and psychological and behavioral needs (Quon & Aitken, 2012). Depressive symptoms and medication nonadherence are emerging as significant risks for adolescents and adults with CF. Like other chronic conditions, the risk for depressive symptoms is elevated (Goldbeck, Besier, Hinz, Singer, & Quittner, 2010; Latchford & Duff, 2013; Riekert, Bartlett, Boyle, Krishnan, & Rand, 2007) and adherence to medications and other treatments is notably low (Briesacher et al., 2011; Eakin, Bilderback, Boyle, Mogayzel, & Riekert, 2011; Nasr, Chou, Villa, Chang, & Broder, 2013; Quittner et al., 2014). Despite these documented risks among people with CF and the known challenges to self-management, little is known about whether or how depressive symptoms relate to adherence to pulmonary medications for CF. One small study of adolescents with CF suggested that youths’ perceptions about their illness and treatments were related to self-reported adherence rates (Bucks et al., 2009), suggesting that beliefs about medications may be related to adherence to CF treatments. However, the role that CF-related medication beliefs play in depressive symptoms and adherence has not been explored, yet is a plausible mediator, given evidence suggesting such associations in other disease groups. No studies have examined a comprehensive set of disease-specific medication beliefs as a potential mechanism indirectly linking depressive symptoms with objectively measured medication adherence in adolescents and adults with CF or in any other chronic condition. Therefore, the aim of this study was to evaluate whether CF-related medication beliefs mediate the relationship between depressive symptoms and adherence to pulmonary medications. It was hypothesized that lower levels of positive medication beliefs, including lower self-efficacy, motivation, and perceived importance of and less optimistic outcome expectancies related to taking medications, would mediate the association between elevated depressive symptoms and suboptimal adherence as measured by 1 year of pharmacy refill data in individuals with CF.

Secondhand smoke exposure (SHSe) is a significant modifiable risk for respiratory health in children. Although SHSe is declining overall, it has increased for low-income and minority populations. Implementation of effective SHSe interventions within community organizations has the potential for significant public health impact.To evaluate the effectiveness of motivational interviewing (MI) delivered in the context of a SHS education reduction initiative within Head Start to reduce preschool children's SHSe.A total of 350 children enrolled in Baltimore City Head Start whose caregivers reported a smoker living in the home were recruited. Caregivers were randomized to MI + education or education alone. Assessments were conducted at baseline, 3, 6, and 12 months.The primary outcome measure was household air nicotine levels measured by passive dosimeters. Secondary outcomes included child salivary cotinine, self-report of home smoking ban (HSB), and smoking status. Participants in the MI + education group had significantly lower air nicotine levels (0.29 vs. 0.40 mg), 17% increase in prevalence of caregiver-reported HSBs, and a 13% decrease in caregiver smokers compared with education-alone group (all P values0.05). Although group differences in salivary cotinine were not significant, among all families who reported having an HSB, salivary cotinine and air nicotine levels declined in both groups (P0.05).MI may be effective in community settings to reduce child SHSe. More research is needed to identify ways to tailor interventions to directly impact child SHSe and to engage more families to make behavioral change. Clinical trial registered with www.clinicaltrials.gov (NCT 00927264).

We sought to understand if pediatrician characteristics and asthma assessment and treatment varied in association with the proportion of African-American and Latino children in the pediatrician's practice.We conducted a cross-sectional survey of 500 American Academy of Pediatrics members between November 2005 and May 2006. Standardized vignettes were used to test how different indicators of a patient's asthma status affect pediatrician asthma assessments and recommendations. Linear and logistic regression models were used to examine the association of pediatrician assessments and treatment recommendations for these vignettes, respectively, with the proportion of reported African-American and Latino children seen in their practice.There were 270 respondents (response rate = 54%). Based on pediatrician-reported percentage of minority patients, there were no differences in board certification status, recognition of poorly controlled asthma nor in the likelihood of appropriately increasing long-term controller medications to treat poorly controlled asthma (p 0.05 for all analyses).Caring primarily for minority children by AAP pediatricians appears unrelated to training qualifications or in their reported knowledge of how to appropriately assess and treat asthma. Therefore, studies of asthma care disparities should focus on understanding the knowledge-base of non-AAP pediatric providers who care for minority populations and exploring other potential contributory provider-level factors (e.g. communication skills).

Effective asthma control is as dependent on patient behavior as it is on guideline-based asthma therapies. More than for many chronic illnesses, asthma management requires patients to be actively engaged in multiple self-management behaviors, including self-monitoring of symptoms, use of an asthma action plan, environmental control practices, and regular adherence with pharmacotherapy using appropriate device technique. When patients are appropriately adherent with these multiple recommendations there is a strong evidence-base that asthma can be very effectively controlled.1 However, multiple studies have found that poor adherence with asthma self-management is very common and a significant contributor to inadequately controlled asthma.2 Studies in adult and pediatric asthma patients suggest that adherence with controller therapies range from 30-70%.3 Less than half of families with asthma complete prescribed environmental control measures to reduce exposure to triggers such as appropriate cleaning measures,4 and dust mite covers, and only one in five families report willingness for pet removal5. Furthermore, up to 55% of patients with asthma still have frequent exposure to nicotine, despite intensive intervention. 6 Poor adherence to asthma self-management guidelines contributes to greater asthma morbidity and mortality.7 Medication nonadherence has been associated with increased symptoms and healthcare utilization8 and more frequent oral steroid bursts.9 Exposure to secondhand smoke has been associated with lower quality of life scores, greater rescue inhaler use, lower lung function, and greater risk for emergency room visits, hospitalization and intensive care unit admission.10 Because of the central role adherence plays in effective asthma control it is critical for clinicians to pay as much attention to patient behavior as to pharmacotherapy. We outline below key factors in promoting optimal patient adherence.

Chronic lung disease of prematurity (CLDP) is a frequent complication of premature birth. Infants and children with CLDP are often prescribed complex medication regimens, which can be difficult for families to manage.We sought to determine whether non-adherence was associated with increased CLDP-related morbidities and to identify predictors of adherence.Recruited caregivers of 194 children with CLDP completed questionnaires regarding self-reported adherence, respiratory outcomes, and quality of life (January 2008-June 2010). Adherence data were available for 176 subjects, of whom 143 had self-reported data only, and 33 had prescription claims data, which were used to calculate a medication possession ratio (MPR). Participants in the Prescription Claims Sample (n = 33) were more likely to have public insurance (P 0.001).Self-reported adherence substantially overestimated medication possession; the mean MPR was 38.8% (n = 33) and was not associated with self-reported adherence (P = 0.71; n = 26). In a small sample, higher MPR was associated with decreased odds ratios of visiting the emergency department (ED) (OR = 0.75 for a 10% increase in MPR [95%CI: 0.58, 0.97]; P = 0.03; n = 74 questionnaires from 28 participants), activity limitations (OR = 0.71 [95%CI: 0.53, 0.95]; P = 0.02; n = 70 questionnaires from 28 participants), and rescue medication use (OR = 0.84 [95%CI: 0.73-0.98]; P = 0.03; n = 70 questionnaires from 28 participants). Increasing caregiver worries regarding medication efficacy and side effects were associated with lower MPR (P = 0.04 and 0.02, respectively; n = 62 questionnaires from 27 participants). Socio-demographic and clinical risk factors were not predictors of MPR (n = 33).We found that non-adherence with respiratory medications was common in premature infants and children with CLDP. Using multiple timepoints in a small sample, non-adherence was associated with a higher likelihood of respiratory morbidities. Although self-reported adherence and demographic characteristics did not predict MPR, concerns about medications did. We suggest that addressing caregiver concerns about medications may improve adherence and ultimately decrease CLDP-related morbidities. Larger, prospective studies are needed to confirm these findings and determine which factors predict non-adherence.

Background The purpose of this study was to identify the extent to which pediatric and adult cystic fibrosis (CF) care teams implement best practices in adherence assessment and counseling. Methods All US CF Foundation accredited programs were invited to participate in a web-based survey; 80% (92/115) of pediatric and 40% (38/95) of adult centers participated. Health care providers reported on current approaches and barriers to implementing adherence promotion practices. Results 64% discussed adherence at every clinic visit while only 8% used an objective assessment of adherence. Most centers reported frequent use of strategies to increase knowledge; behavioral and support strategies were used less regularly. Several barriers to adherence promotion were reported. Conclusions Many opportunities exist for care teams to improve consistency in adherence practices and integrate a greater repertoire of effective counseling strategies into clinic visits. Adherence promotion practices should be considered for quality improvement (QI) projects.

The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested.

Background Indigenous populations in Latin America have worse health outcomes than their nonindigenous counterparts. Differences in access to and use of biomedical resources may explain some of the observed disparities. Efforts to address these differences could be aided in part by better understanding the socio-medical contexts in which they occur. Methods We performed a qualitative analysis of field notes collected during a 2008 program evaluation of a health post in a rural Maya village in Sololá Department, Guatemala. Forty-one interviews were conducted among a community-based convenience sample of adult men and women. Interviews focused on experiences, perceptions, and behaviors related to the local biomedical and ethnomedical health care resources. Results Penetrance of the local health post was high, with most (90%) of respondents having accessed it within the prior five years. The prevailing attitude toward the health post was positive. We identified facilitators and barriers to health post use that corresponded with three thematic areas: clinic operations, visits and consultations, and medical resources. Proximity to the home, free consultations and medications, and social support services were among the most commonly cited facilitators. Barriers included limited clinic hours, medication stock-outs, provision of care that did not meet patient expectations, and unavailability of diagnostic tests. Conclusions In a rural Maya community in Guatemala, operational and quality-based factors, independent of sociocultural considerations, informed the perception of and decision to access biomedical resources. Interventions that address these factors may increase health care utilization and alleviate some of the health disparities that accompany indigeneity in Guatemala and similar contexts.

Background There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness. Methods We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework. Results A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability. Conclusion ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental, physical, social, and functional sequelae occur after hospital discharge. These findings are important for understanding patient-centered outcomes in critical care and providing focus for future interventional studies aimed at improving outcomes of importance to ICU survivors. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1516-x) contains supplementary material, which is available to authorized users.