Organ Transplant Social Work and Psychosocial Predictors of Medication Adherence

Background: Social workers on multidisciplinary organ transplant teams play a critical role in the transplant process when providing services to pediatric patients and their families. Research on the psychosocial predictors of medication adherence is critical to the advancement of pretransplant assessments and transplant social work services. This paper presents practice-based research aimed at identifying those children, and their families, most at risk for future non-adherence to life-prolonging, immunosuppressive medications following a heart or lung transplant.

Methods: Hospital-generated data and medical records information were used to test the association between patient and family psychosocial characteristics and medication adherence. Data generated from the United Network for Organ Sharing (UNOS; Department of Health and Human Services) offered medical information and patient and family demographics. All children and their caregivers received psychosocial assessments by transplant social workers prior to being listed for a transplant. Medication adherence outcomes were obtained using the physician reports found in the UNOS data and measured through patient-level standard deviation scores of immunosuppressive medication blood tests.

Results: Complete data was collected on 105 pediatric heart and lung transplant recipients and their families. The children were predominantly male (57%), white (65%), heart transplant recipients (78%), and a mean age at transplant of 10.1 years (sd=6.0). A majority of the parents had an educational level below a four-year college degree (70%), were from a two-parent or blended family home (64%), and had public insurance (70%).

In the bivariate analyses, age of the child at transplant, organ type, time of the pretransplant diagnosis, medical status (ICU) at time of listing for transplantation, and patient on life-support predicted standard deviation scores of the medication blood levels. The physician’s report of the patient’s adherence was predicted by age of the child at transplant, child experience of maltreatment, having private insurance, greater parental level of education, having a two-parent home,  quality family communication, and patient on life-support.

Multivariate, step-wise analyses were conducted with each adherence outcome. The model predicting the physician reports of the patient’s adherence included age of the child at transplantation, parental education, two-parent families, other significant psychosocial problems, and the pretransplant life support status of the child. The resulting model (χ²=28.146, df=5, p<.001) explained approximately 39.5% of the variance in the physician reports of adherence (Nagelkerke R²=.395). The medication blood level standard deviation scores were predicted by age at transplant (F=5.624, p<.02, R²=.05).

Conclusions: The ability to assess children and their families for psychosocial risk factors of non-adherence is central to their care and the efforts of social workers on these teams. Results point to the difficulties experienced by these children, and their families, when undergoing a heart or lung transplantation. Efforts to develop standardized and evidence-based pretransplant psychosocial assessments in pediatric populations are suggested, especially those surrounding familial risk factors. Family-centered approaches to the promotion of adherence are recommended during pretransplant and posttransplant periods. This study also demonstrates the value of available records and administrative information during practice-based research conducted in collaboration with social work practitioners.