The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma
Introduction
Minority adolescents have disproportionately high morbidity and mortality for asthma compared to white adolescents. Mortality rates for 11–17-year-old children are higher than younger children based on national data, and African-American children have a significantly higher rate of emergency room visits, hospitalizations and mortality than white children [1]. Many studies have found that adolescents with asthma have poorer adherence than younger children and that the decline begins around age 10 years [2], [3]. Studies also find that minority children have significantly lower adherence than Caucasian children [3]. Non-adherence to asthma controller therapy therefore may be related to excess morbidity and mortality from asthma in adolescent inner-city predominantly minority populations.
Recent meta-analyses concluded that pediatric self-management interventions have demonstrated efficacy and should be considered standard in routine asthma care [4], [5]. Such interventions, however, do not usually assess adherence, include a wide age range, or evaluate the efficacy of the intervention specifically for minority participants. It is therefore difficult to draw conclusions about the efficacy of existing asthma self-management interventions for minority adolescents. We identified only six studies that focused exclusively on adolescent participants. Three “tailored” the intervention for adolescents by having teenage peers deliver asthma education [6], [7] or allowing the adolescent to bring a friend to an asthma intervention at a mall [8]. Of the remaining three [9], [10], [11], all acknowledged the need for tailoring but none specified how their intervention was customized for adolescents. While three of these six studies showed improvement for at least one health outcome [6], [10], [11], only two studies assessed medication adherence. van Es et al. [9] tested the effectiveness of a 1-year clinic-based intervention involving individual asthma education and group sessions that focused on coping with asthma, communication, and problem-solving, compared to a usual care group. At 24 months, self-reported adherence was higher in the treatment group; however, these results were not significant at the 12-month assessment and are limited by poor follow-up rates. The second study targeted urban African-American adolescents and tested a 4-session computer-based education intervention focusing on controller medication adherence, rescue inhaler availability, and smoking, compared to an attention control group receiving generic asthma information [11]. Although the authors reported a trend for “positive changes” in self-reported controller medication adherence, the term was never defined. Taken together, these studies suggest that developmentally appropriate, culturally sensitive, innovative approaches to assist African-American adolescents to follow medication regimens are needed.
Social Cognitive Theory (SCT) is widely used in health promotion [12]. SCT proposes that motivation and behavior are functions of an individual's motivation, outcome expectancies, and perceived self-efficacy. Research supports the hypothesis that high self-efficacy is associated with better asthma medication adherence, and studies have shown that interventions targeting self-efficacy improve short-term adherence [13], [14], [15], [16]. Most SCT-based interventions use education and behavior modification techniques to improving adherence and are predicated on the questionable assumption that participants are motivated to change: they rarely attempt to build motivation. High self-efficacy without comparable levels of motivation to change can lead to decreased likelihood of change [17]. Interventions taking a prescriptive, educative stance may paradoxically increase resistance among participants who are not ready to change [18], [19]. Motivation to adhere to asthma medications has received little research attention, particularly among adolescents. Studies have found that adolescents with higher motivation to take medication self-report higher adherence across a variety of chronic illness groups, including asthma [20], [21], [22], [23], [24].
Motivational Interviewing (MI) is a patient-centered approach to health behavior change that helps patients to resolve ambivalence about change and enhances intrinsic motivation [25], [26]. MI helps the individual weigh the pros and cons for change, build intrinsic motivation for change, and facilitate collaborative decision-making prior to implementing education and problem-solving strategies. MI may be developmentally appropriate for adolescents because it promotes personal control and autonomous decision-making for change, focuses on individualized goals and values and their relation to the target behavior, and calibrates the approach to the teen's readiness to change. MI does not assume that health is the most important factor motivating the adolescent, but rather acknowledges and incorporates other motivators within the unique context of the teen's life. Because the adolescent is integral to deciding whether to change, selecting goals, determining and implementing the plan to achieve the goals, MI is developmentally supportive of the adolescent's emerging independence in self-care, yet sensitive to the cultural and social needs of the adolescent and family. Several studies have tested MI in adolescents across a variety of health behaviors, including smoking, alcohol/drug use, diet, physical activity, and diabetes management and have demonstrated improvements in outcomes [27], [28], [29], [30], [31], [32], [33].
Only one study in adults has evaluated MI as a strategy to promote asthma medication adherence [34]. In this study [34], 25 adults with asthma were randomly assigned to one of two conditions: a brief educational intervention, or education plus MI. While the education condition significantly increased knowledge scores, participants demonstrated a reduction in motivation for change. Participants receiving MI, however, showed significant increases in motivation compared to those in the education condition. No adherence or asthma morbidity data were collected.
The purpose of our non-randomized pilot study was to develop an MI-based self-management intervention to improve asthma medication adherence among inner-city, African-American adolescents. We gathered data on the acceptability and satisfaction of the intervention from the families and tested whether this pilot intervention resulted in pre-post-changes in caregiver- and adolescent-reported adherence and mediator variables of theoretical relevance to MI and medication adherence, including the motivation, readiness, and self-efficacy to adhere to an asthma regimen. We hypothesized that adolescents post-intervention would have higher levels of adherence and motivation, increased readiness to change, and greater self-efficacy to adhere to their asthma medication regimen compared to baseline. We also examined change in caregiver-adolescent responsibility for treatment to evaluate unintended negative consequences (e.g., the caregiver abdicating responsibility for asthma management without the adolescent assuming responsibility).
Section snippets
Participants
Potential participants were identified from an urban pediatric Emergency Department (ED). Adolescents were eligible for the study if they were age 10–15 years old at the time of the ED visit, lived in the city, were treated in the ED or hospitalized for an asthma exacerbation, and were prescribed a daily asthma controller medication (either an inhaled corticosteroid (ICS) or a leukotriene modifier (LM)). Exclusion criteria included foster care or incarceration, not English speaking, or
Adherence
At baseline, 46% of caregivers and 32% of adolescents reported the adolescent took her/his ICS every day during the 2 previous weeks. At post-intervention, the caregiver report of perfect medication adherence increased from baseline (62%), but adolescent report did not change (27%; χ2 = 5.5, p = .02 for caregivers and χ2 = 1.9, p = .17 for adolescents). There were no significant changes in mean ratings of ICS medication doses taken in the previous 2 weeks by either caregiver or teen report (p = .14 and p =
Discussion
MI has been successfully used to promote health behavior change across a wide variety of illnesses, but only one study [34] used MI to motivate asthma medication adherence and this was among adults. Moreover, only a handful of studies have focused on increasing asthma medication adherence in adolescents [6], [7], [8], [9], [10], [11]. Intervention strategies of prior studies assume that adolescents are ready and willing to change. MI does not make these assumptions, but rather targets these
Conflict of interest
None.
Role of funding
Grant HL063333 awarded to Cynthia S. Rand by the National Heart Lung Blood Institute provided financial support for the conduct of the research. The funding agency had no involvement in the interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Acknowledgements
None.
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