Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review

Abstract

Introduction: Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions. Methods: Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention.Results: Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence. Conclusion:Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.

Effect of monitoring adherence to regular inhaled corticosteroid (ICS) alone or in combination with a long-acting β2-agonist (LABA) using electronic methods on asthma outcomes: a narrative systematic review

“…A narrative-systematic review conducted by Pearce et al among children with asthma included one study evaluating a web‐based interactive education and monitoring system based on social cognitive theory and eHealth theoretical models compared with receiving an asthma education manual among 42 asthmatic children. Compared with the baseline adherence rate for both groups (38%), the mean change in adherence increased by 11.2% in the intervention group to a 4.4% decrease in the control group (p=0.67) 21…”

“…The mean adherence rates during the 30-day intervention were 34% for the intervention group and 40% for the control (p=0.56). There was also no significant difference between the intervention and control groups after adjusting for age and parental education, with none of the cases exceeding the 80% adherence threshold (control=32% vs intervention=36%, p=0.73) 21…”

“…Based on abstract screening, 1166 articles were excluded for reasons, including descriptive studies having no adherence outcomes measured, editorials, opinion papers and studies that included oral asthma or non-asthma medications. After screening abstracts, 121 articles were eligible for full-text review of which only six published articles (five systematic reviews and one RCT) were eligible for inclusion in this study narrative review synthesis 18–23. Reasons for exclusions included overlap studies appearing in included systematic review outputs, articles not related to ICS adherence (eg, diagnosis, feasibility), articles not reporting research design or methodologies, availability restricted to a conference abstract, articles only reporting study protocols, self-report studies, pharmacy refill data or no full-text paper available.…”

“…The third study compared the adherence interventions among asthmatic children with EMDs with audio‐visual enabled (intervention group) to EMDs with audio‐visual disabled (control group) every 2 months for 6 months period 26. The median adherence in the intervention group was 84% (10th/90th percentile 54%–96%), compared with 30% in the control group (10th/90th percentile 8%–68%), p<0.0001 21. A meta-analysis of 10 RCTs by Lee et al evaluated EMDs with clinical feedback compared with usual care or placebo group among 1123 asthmatic children and revealed that the EMD group was 1.50 times (RR=1.50, 95% CI 1.19 to 1.90) more likely to adhere to inhaler therapy compared with the control group (p<0.001) with medium-to-large effect size (g=0.64).…”

Medication nonadherence: health impact, prevalence, correlates and interventions

“…Many interventions have been designed to support adherent behaviour across a range of conditions and treatments with varying degrees of efficacy (e.g. Chan et al, 2018;Conn & Ruppar, 2017;Horne, 1998;Kripalani et al, 2007;MacDonald et al, 2016;Nieuwlaat et al, 2014;Pearce et al, 2022). One systematic review found that only 16 out of 37 trials reported an improvement in adherence across chronic conditions, and suggested that interventions involving monitoring and feedback, or reducing dosing demands were most likely to be effective (Kripalani et al, 2007).…”