The In Vivo Adherence Intervention For at Risk Adolescents With Asthma: Report of a Randomized Pilot Trial

Despite existing national guidelines and efficacious treatments (National Asthma Education and Prevention Program, 2007), asthma, one of the most common pediatric chronic illnesses (U.S. Department of Health and Human Services, 2000), lowers health-related quality of life (HRQOL) (Forrest, Starfield, Riley, & Kang, 1997) and increases school absence (National Asthma Education and Prevention Program, 2003) and hospitalization (Centers for Disease Control and Prevention, 2005). Most seriously, asthma kills—disproportionately so for adolescents (twice the risk of mortality compared to younger children) and for non-Hispanic Blacks (four times the risk of mortality compared to non-Hispanic whites) (Akinbami & Schoendorf, 2002; American Lung Association, 2006). Excellent clinical care is necessary but not sufficient for asthma control (Finkelstein et al., 1995; Lozano, Finkelstein, Hecht, Shulruff, & Weiss, 2003). Good self-management is also required, but nonadherence to treatment is problematic in pediatric asthma (Graves, Roberts, Rapoff, & Boyer, 2010; Rohan et al., 2010). Nonadherence is a major contributor to poor control in children sampled in care settings (Bracken et al., 2009; Stanford et al., 2010), and prospective monitoring of asthma medication adherence shows that youth use 31.5% of prescribed corticosteroid treatments (Rohan et al., 2010). Low-income, minority adolescents are at particular risk for both poor asthma outcomes and low rates of adherence to treatment. Non-Hispanic Black children are twice as likely to have ever been diagnosed and to still have asthma (22% and 17%) as their Non-Hispanic white peers (12% and 8%). Rates for children in poor families (18% and 14%) are similarly higher than their nonpoor peers (13% and 8%) (Bloom, Cohen, & Freeman, 2010). And Non-Hispanic Black children visit emergency departments, are hospitalized, and experience death due to asthma at rates at least three times higher than rates for Non-Hispanic white children (Centers for Disease Control and Prevention, 2010). A variety of causes, including access to care, gene–environment interactions, environmental allergens, and nutrition contribute to these disparities (Hill, Graham, & Divgi, 2011). Proper use of asthma medications is also a likely culprit: National survey data suggest that African-American children are one-third as likely to have used inhaled corticosteroids in the past 3 months and twice as likely to have used daily short-acting β-agonists (Crocker et al., 2009). While there are multiple contributors to nonadherence, most theories of health behavior posit that, in addition to knowledge, both motivation and skills are necessary to change behavior (Curry & Emmons, 1994; Fisher, Fisher, Amico, & Harman, 2006; Weinstein, Rothman, & Sutton, 1998). Indeed, interventions to enhance motivation and build skills have been shown to be efficacious in changing a variety of health behaviors, though have been less studied in adolescents with asthma (Graves et al., 2010; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). Motivational interviewing (MI), a patient-centered approach to health behavior change, helps patients to resolve ambivalence about change and enhances intrinsic motivation by creating a motivational frame for change (Rollnick, Miller, & Butler, 2008). Two recent meta-analyses have summarized MI's efficacy (Lundahl et al., 2010; Rubak, Sandbaek, Lauritzen, & Christensen, 2005). In adolescent populations, MI techniques have been shown to be efficacious in reducing harmful alcohol and drug use (Barnett, Monti, & Wood, 2001; D'Amico & Edelen, 2007; D'Amico, Miles, Stern, & Meredith, 2008; Spirito et al., 2004), smoking (Colby et al., 2005), and HIV risk behaviors (Naar-King et al., 2006). A multisite randomized trial showed that MI in adolescents with diabetes reduced hemoglobin A1C and improved HRQOL (Channon et al., 2007). ‘Problem solving’ is the behavior process through which individuals manage daily barriers to adherence and adjust their self-care regimen accomplish adherence (D'Zurilla, 1986; Nezu, Nezu, Felgoise, McClure, & Houts, 2003). Problem-solving interventions have been shown to be efficacious with parents of children with chronic health conditions (Varni, La Greca, & Spirito, 2000) including asthma (Seid, Varni, Gidwani, Gelhard, & Slymen, 2010), cancer (Sahler et al., 2005), traumatic brain injury (Wade, Wolfe, Brown, & Pestian, 2005), attention-deficit hyperactivity disorder (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; McCleary & Ridley, 1999), and oppositional defiant disorder (Greene, Ablon, & Goring, 2003). Although problem-solving has been relatively less studied in adolescent populations, it has been shown, in adolescents with Type 1 diabetes, to improve self-efficacy (Howells et al., 2002), metabolic control through increased frequency of blood glucose testing (Cook, Herold, Edidin, & Briars, 2002), anxiety, stress, and coping (Hains, Davies, Parton, Totka, & Amoroso-Camarata, 2000), and quality of life (Grey, Boland, Davidson, Li, & Tamborlane, 2000). An intervention that combines MI and problem-solving skills training (PSST) may be particularly appropriate for adolescents. MI emphasizes a collaborative process, ensuring cultural appropriateness and acceptability for adolescents, given developmental trajectories of self-determination (Cook et al., 2002; Velsor-Friedrich, Vlasses, Moberley, & Coover, 2004) and adolescents’ tendency to respond more positively to a motivational approach (Brown & D'Amico, 2001; D'Amico, 2005; D'Amico & Fromme, 2002) and to prefer an interactive versus didactic style (D'Amico & Edelen, 2007). PSST is useful for this age group as adolescents expand their range of experiences and situations and thus, opportunities for problem-solving. Text messaging is also culturally appropriate and a pervasive form of communication for adolescents. Tailored text messaging could strengthen adherence interventions for adolescents. Neurocognitive research (Paus, 2005; Steinberg, 2005) suggests that the adolescent brain is still developing and that adolescents are highly susceptible to social and emotional stimuli and relatively poor at assessing risk, particularly when excited or under stress (Steinberg, Cauffman, Woolard, Graham, & Banich, 2009). Thus, text messages may serve as a bridge from the in-person component of an intervention to the adolescent's ‘real’ life (hence “In Vivo”). Current data for the efficacy of text-messaging, however, is mixed: Text messaging was associated with improved adolescent adherence to medication post liver transplant, but this single-group pre-post trial had no control group (Miloh et al., 2009). Sweet-Talk, a text-message system for adolescents with diabetes, was shown in a randomized clinical trial to be efficacious with respect to self-efficacy and self-reported adherence, but not clinical outcomes (Franklin, Waller, Pagliari, & Greene, 2006). Despite these promising approaches, however, there are very few interventions to enhance adherence in low-income adolescents with asthma, and none that combine the three elements of MI, PSST, and text messaging. A single published report exists to demonstrate the efficacy of MI in promoting asthma medication adherence in inner-city African-American adolescents (Riekert, Borrelli, Bilderback, & Rand, 2011). While MI was shown to improve motivation, readiness to change, and asthma quality of life, the single-group pre-post design of this study limits conclusions. A randomized trial testing an interdisciplinary asthma self-management intervention that included problem-solving as the main behavioral intervention resulted in less utilization, but neither asthma symptoms nor health-related quality of life differed between groups (Walders et al., 2006). No trials of texting exist yet for adolescents with asthma. This gap in the knowledge base has significant implications for treating this at-risk population. To address this need, we present a theoretically-driven adherence intervention for adolescents with asthma that combines MI and PSST with tailored text messaging. We describe acceptability, feasibility, fidelity, and estimated effect sizes of an adherence intervention that integrates MI, PSST, and text messaging to reduce asthma symptoms and improve HRQOL in a sample of predominantly low-income African-American adolescents with moderate- or severe-persistent asthma. We also test for estimated effects for increased motivation, intention to change, patient activation and reduced barriers to adherence.