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Evidence-Based Medicine: Commentary |

Overview of the Management of CoughManagement of Cough Overview: CHEST Guideline and Expert Panel Report FREE TO VIEW

Richard S. Irwin, MD, Master FCCP; Cynthia T. French, PhD, ANP-BC; Sandra Zelman Lewis, PhD; Rebecca L. Diekemper, MPH; Philip M. Gold, MD, FCCP; on behalf of the CHEST Expert Cough Panel
Author and Funding Information

From the Division of Pulmonary, Allergy & Critical Care Medicine (Drs Irwin and French), UMass Memorial Medical Center, Worcester, MA; CHEST (Dr Lewis and Ms Diekemper), Glenview, IL; and Loma Linda University Medical Center (Dr Gold), Loma Linda, CA.

CORRESPONDENCE TO: Richard S. Irwin, MD, Master FCCP, UMass Memorial Medical Center, 55 Lake Ave, North Worcester, MA 01655; e-mail: Richard.Irwin@umassmemorial.org


Dr Lewis currently is with EBQ Consulting, LLC, Northbrook, IL.

FUNDING/SUPPORT: CHEST was the sole supporter of these guidelines, this article, and the innovations addressed within.

DISCLAIMER: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1464S1.

Editor’s Note: This is the first of a series of articles that is part of the CHEST Organization’s update of its 2006 Evidence-Based Clinical Practice Guidelines on the Diagnosis and Management of Cough. You may have already seen it online ahead of print. The subject matter that will comprise this new Cough Guideline and Expert Panel Report is tabulated in this article. While this article and selected others will appear in print as well as online, look for the entire spectrum of topics that will be progressively updated online during the course of the coming months to several years.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(4):885-889. doi:10.1378/chest.14-1485
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Published online

This overview will demonstrate that cough is a common and potentially expensive health-care problem. Improvement in the quality of care of those with cough has been the focus of study for a variety of disciplines in medicine. The purpose of the Cough Guideline and Expert Panel is to synthesize current knowledge in a form that will aid clinical decision-making for the diagnosis and management of cough across disciplines and also identify gaps in knowledge and treatment options.

In neurophysiologic and acoustical terms, cough arises following activation of a complex sensorimotor reflex arc whose sound can be easily identified by the human ear. The distinctive sound is generated by the explosive release of trapped and pressurized intrathoracic air from the sudden opening of the vocal folds.1 Because cough is an easily described and recognizable physical act, patients know what is being referred to as cough, thereby lending credibility to findings from patient surveys on prevalence of cough. This has also enabled investigators to develop cough-specific, patient-reported outcome tools by which physicians can assess the impact of cough on patients. Moreover, because the sound resulting from coughing has a typical acoustic waveform profile, software detection algorithms for automatic monitoring2 have been developed for cough counting.

While cough in healthy individuals is physiologically important, it typically is of little clinical importance because it is normally a very uncommon event.3,4 Nevertheless, it assumes great importance as (1) a defense mechanism when it helps clear excessive secretions and foreign material from the airways, (2) a factor in the spread of infection, (3) a patient-initiated tactic to provide cardiopulmonary resuscitation to maintain consciousness during a potentially lethal arrhythmia and/or convert arrhythmias to a normal rhythm,5,6 and (4) a common symptom for which patients seek medical attention. While we acknowledge that cough can be viewed from a variety of perspectives, the focus of this update of the 2006 guidelines7 will be on managing cough as a symptom and when its defense mechanism function has been impaired. Moreover, while the majority of topics in this update will be written to aid practicing clinicians in a variety of disciplines, as well as patients, other topics such as those that appear in Table 1 also target basic and clinical researchers as the intended users.

Table Graphic Jump Location
TABLE 1 ]  Spectrum of Topics for the Third Edition of the CHEST Cough Guidelines
a 

While cough due to many conditions such as asthma and aspiration will be discussed in the chronic category, these conditions can present acutely and subacutely. Nevertheless, the same principles of management apply once the diagnosis is made.

Recognition by the American College of Chest Physicians (CHEST) of the importance of cough in clinical practice in the United States was the impetus for developing the first evidence-based cough guideline, published in 1998.8 Since then, and the publication of the second edition in 2006,7 the impact of cough on global health has attained widespread recognition. Published cough guidelines, albeit of varying quality and foci (eg, adults, pediatrics, acute cough, chronic cough, cough in palliative care), have been developed by organizations not only from the United States7 but also from Australia,9 Belgium,10 Brazil,11 China,12 Germany,13 United Kingdom,14 Ireland,15 Netherlands,16 Japan,17 South Africa,18 and Spain.19 Prevalence data from Australia, Great Britain, Japan, and the United States provide the putative reason for the widespread interest in developing cough guidelines. Government-generated statistics from Australia20 and the United States21 reveal that cough of undifferentiated duration is the single most common complaint for which patients of all ages seek medical care from primary care physicians in the ambulatory setting. Surveys in Japan22 and Great Britain23 suggest that the prevalence of chronic cough in the general population is 10.2% and 12%, respectively. Further, financial data derived from the over-the-counter market for cough and cold remedy products that are of doubtful benefit and potentially harmful for young children7 support the statistics that cough is a very troublesome symptom. According to a survey conducted for the CHEST Expert Cough Panel in US dollars by The Nielsen Company,24 consumers spent (1) approximately $6.8 billion in the United States for the 52-week period that ended on March 16, 2013; (2) approximately $88 million in Australia for the 52-week period that ended December 16, 2012; (3) approximately $101 million in Canada for the 52-week period that ended on March 9, 2013; and (4) approximately $156 million in Great Britain for the 52-week period that ended March 30, 2013. While these countrywide figures are large, especially in the United States, they greatly underestimate the total cost of treating cough. They do not reflect the total economic burden of direct costs that include the physician fees, radiographs, and laboratory testing, and the cost of prescription drugs for the myriad causes of cough other than the common cold and indirect costs, such as time missed from work.

In its deliberations regarding how to update the second edition of these guidelines and advance the field, the Expert Panel unanimously decided to cover the same comprehensive spectrum of topics (Table 1), albeit in a different order, to keep the publication up to date and clinically useful, while doing so according to the more rigorous, evidence-based methodologies25 that have evolved since the last publication.7 While the panelists believed that all clinically important topics would be covered in this update, they not only acknowledged that the final titles of topics listed in Table 1 might be modified but also knew that they would be able to add additional ones should the need arise, because the update would be an evolving process developed over time. To satisfy all of these objectives, even when the evidence on some topics was not robust enough for guideline recommendations, the Expert Panel sought and received approval from the CHEST organization’s Guidelines Oversight Committee for creating a hybrid model for providing advice regarding the diagnosis and management of cough. This current publication is a product of this hybrid model; it provides a combination of recommendations derived from clinical practice guideline methodology and suggestions derived from consensus statement methodology (one component of which is a modified Delphi process for consensus achievement).26 The specifics of how this was accomplished are described in the methodology article in this report.26 Moreover, to keep this publication and all guidelines as current as possible, the CHEST organization has developed and implemented its “living guidelines” model,25,27 whereby topics are reviewed for possible updating on an annual basis, and when new evidence or interventions demand it, they are updated. To avoid delays in publishing, these updates will be added to the literature as soon as updates are finalized, and the full scope of topics, in their entirety, will appear over a 4-year period.

In addition to these advances, the current set of topics focuses on the concept of intervention fidelity,28 because the lack of attention to it may help explain some of the varying successes in treating chronic cough that have been reported in the literature. Intervention fidelity is the “extent to which an intervention was delivered as conceived and planned to arrive at valid conclusions concerning its effectiveness in achieving target outcomes.”29 Because of the importance of this concept, the Expert Panel suggests that it be included in the design of studies of cough and how it might be addressed to prospectively avoid and assess the problem (R. S. I. and C. T. F., unpublished data, 2014).

As cough is a global problem managed by a variety of disciplines, these guidelines and the Expert Panel Report represent the interprofessional, collaborative efforts of an international group of 53 individuals from the fields of adult and pediatric pulmonology and respirology, internal medicine and family medicine, allergy, psychology, neurology, adult and pediatric speech pathology, otolaryngology, gastroenterology, gerontology, infectious disease, nursing, anatomy, physiology, thoracic oncology, palliative care, and pharmacy. Methodologists and representatives for lay consumers and the US Food and Drug Administration also served on the Panel and provided invaluable insights.

Author contributions: R. S. I. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. R. S. I. wrote the first draft of the manuscript and C. T. F., S. Z. L., R. L. D., and P. M. G. reviewed and contributed to subsequent versions. All five authors served on the Executive Committee of the Panel, led by R. S. I. as the Panel Chair.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: While Dr Irwin, as Editor in Chief of CHEST, discloses that part of his salary is paid for by CHEST, he has received no financial support for participating on the Expert Cough Panel. Dr Irwin discloses that the review of this manuscript and the ultimate decision to publish it was made by others without his knowledge. While Dr French, as Assistant to the Editor in Chief of CHEST, discloses that part of her salary is paid for by CHEST, she has received no financial support for participating on the Expert Cough Panel. Dr Lewis makes public statements and gives presentations about the CHEST Guideline Methodology at conferences and other meetings on this topic. Her expenses are sometimes reimbursed. She received one small honorarium ($150) from the Institute of Medicine in 2011. Ms Diekemper is an author of the DART tool, used to assess the quality of systematic reviews, but receives no compensation for it. Dr Gold has reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: CHEST was the sole supporter of these guidelines, this article, and the innovations addressed within.

Collaborators: Todd M. Adams, MD; Kenneth W. Altman, MD, PhD; Alan F. Barker, MD; Surinder S. Birring, MBChB, MD; Donald C. Bolser, PhD; Louis-Philippe Boulet, MD, FCCP; Sidney S. Braman, MD, FCCP; Christopher Brightling, MBBS, PhD, FCCP; Priscilla Callahan-Lyon, MD; Brendan Canning, PhD; Anne Bernadette Chang, MBBS, PhD, MPH; Remy Coeytaux, MD, PhD; Terrie Cowley, BA; Paul Davenport, PhD; Satoru Ebihara, MD, PhD; Ali A. El Solh, MD, MPH; Patricio Escalante, MD, FCCP; Stephen K. Field, MD; Dina Fisher, MD; Peter Gibson, MBBS; Michael K. Gould, MD, FCCP; Susan M. Harding, MD, FCCP; Anthony Harnden, MBChB; Adam T. Hill, MBChB, MD; Peter J. Kahrilas, MD; Karina A. Keogh, MD; Andrew P. Lane, MD; Kaiser Lim, MD; Mark A. Malesker, PharmD, FCCP; Peter Mazzone, MD, MPH, FCCP; Douglas C. McCrory, MD, MHS; Lorcan McGarvey, MD; M. Hassan Murad, MD, MPH; Peter Newcombe, PhD; Huong Q. Nguyen, PhD, RN; John Oppenheimer, MD; David Prezant, MD; Tamara Pringsheim, MD; Marcos I. Restrepo, MD, FCCP; Mark Rosen, MD, Master FCCP; Bruce Rubin, MD, MEngr, MBA; Jay H. Ryu, MD, FCCP; Jaclyn Smith, MBChB, PhD; Susan M. Tarlo, MBBS, FCCP; Ronald B. Turner, MD; Anne Vertigan, PhD, MBA; Kelly Weir, MsPath; Renda Soylemez Wiener, MD, MPH.

Other contributions: We thank other panelists and association representatives participating in the guidance development process for their review of this article.

CHEST

American College of Chest Physicians

Irwin RS. Cough.. In:Irwin RS, Curley FJ, Grossman RF., eds. Symptoms of the Respiratory Tract. Armonk, NY: Futura Publishing Co, Inc; 1997:1-54.
 
Smith JA, Earis JE, Woodcock AA. Establishing a gold standard for manual cough counting: video versus digital audio recordings. Cough. 2006;2:6. [CrossRef] [PubMed]
 
Loudon RG. Cough in health and disease. Aspen Emphysema Conf. 1967;10:41-53. [PubMed]
 
Sumner H, Woodcock A, Kolsum U, et al. Predictors of objective cough frequency in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013;187(9):943-949. [CrossRef] [PubMed]
 
Schultz DD, Olivas GS. The use of cough cardiopulmonary resuscitation in clinical practice. Heart Lung. 1986;15(3):273-282. [PubMed]
 
Jafary FH. Cough-assisted maintenance of perfusion during asystole. Can J Cardiol. 2008;24(10):e76. [CrossRef] [PubMed]
 
Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1_suppl):1S-23S. [CrossRef] [PubMed]
 
Irwin RS, Boulet L-P, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians. Chest. 1998;114(2_suppl):133S-181S. [CrossRef] [PubMed]
 
Gibson PG, Chang AB, Glasgow NJ, et al; CICADA. CICADA: Cough in children and adults: diagnosis and assessment. Australian cough guidelines summary statement. Med J Aust. 2010;192(5):265-271. [PubMed]
 
Leconte S, Paulus D, Degryse J. Prolonged cough in children: a summary of the Belgian primary care clinical guideline. Prim Care Respir J. 2008;17(4):206-211. [CrossRef] [PubMed]
 
[II Brazilian guidelines for the management of chronic cough]. J Bras Pneumol. 2006;32(suppl 6):S403-446. [CrossRef] [PubMed]
 
Asthma Workgroup, Chinese Society, Respiratory, Diseases (CSRD), Chinese Medical, Association. The Chinese national guidelines on diagnosis and management of cough (December 2010). Chin Med J (Engl). 2011;124(20):3207-3219. [PubMed]
 
Kardos P, Berck H, Fuchs KH, et al; German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough. Guidelines of the German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough. Pneumologie. 2010;64(11):701-711. [CrossRef] [PubMed]
 
Morice AH, McGarvey L, Pavord I, et al. Recommendations for the management of cough in adults. Thorax. 2006;61(suppl 1):i1-24. [CrossRef] [PubMed]
 
Wee B, Browning J, Adams A, et al. Management of chronic cough in patients receiving palliative care: review of evidence and recommendations by a task group of the Association for Palliative Medicine of Great Britain and Ireland. Palliat Med. 2012;26(6):780-787. [CrossRef] [PubMed]
 
Verlee L, Verheij TJ, Hopstaken RM, Prins JM, Salomé PL, Bindels PJ. Summary of NHG practice guideline ‘Acute cough’ [in Dutch]. Ned Tijdschr Geneeskd. 2012;156(0):A4188. [PubMed]
 
Kohno S, Ishida T, Uchida Y, et al. The Japanese Respiratory Society guidelines for management of cough. Respirology. 2006;11(suppl 4):S135-186. [PubMed]
 
English RG, Bateman ED, Zwarenstein MF, et al. Development of a South African integrated syndromic respiratory disease guideline for primary care. Prim Care Respir J. 2008;17(3):156-163. [CrossRef] [PubMed]
 
Plaza V, Miguel E, Bellido-Casado J, Lozano MP, Ríos L, Bolíbar I. Usefulness of the Guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) in identifying the causes of chronic cough [in Spanish]. Arch Bronconeumol. 2006;42(2):68-73. [CrossRef] [PubMed]
 
Britt H, Miller G, Henderson J, et al. General Practice Activity in Australia 2011-12: General Practice Series No.31. Sydney, Australia: University of Press; 2012.
 
Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 outpatient department summary tables. 2013. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010_opd_web_tables.pdf. Accessed July 30, 2013.
 
Fujimura M. Frequency of persistent cough and trends in seeking medical care and treatment-results of an internet survey. Allergol Int. 2012;61(4):573-581. [CrossRef] [PubMed]
 
Ford AC, Forman D, Moayyedi P, Morice AH. Cough in the community: a cross sectional survey and the relationship to gastrointestinal symptoms. Thorax. 2006;61(11):975-979. [CrossRef] [PubMed]
 
The Nielsen Company (US), LLC. Market surveys for over the counter cough and cold products [unpublished survey created for Richard S. Irwin, MD]. The Nielsen Company website. http://www.nielsen.com/us/en.html. Published 2013. Accessed April 15, 2013.
 
Lewis SZ, Diekemper R, Ornelas J, Casey KR. Methodologies for the development of CHEST guidelines and expert panel reports. Chest. 2014;146(1):182-192. [CrossRef] [PubMed]
 
Diekemper R, Lewis SZ, French C, Gold P, Irwin R. Methodologies for the development of the management of cough: CHEST guideline and expert panel report. Chest. In press.
 
Metersky ML, Nathanson I. Introducing the future of ACCP clinical practice guidelines. Chest. 2012;141(2):285-286. [CrossRef] [PubMed]
 
Bellg AJ, Borrelli B, Resnick B, et al; Treatment Fidelity Workgroup of the NIH Behavior Change Consortium. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23(5):443-451. [CrossRef] [PubMed]
 
Song MK, Happ MB, Sandelowski M. Development of a tool to assess fidelity to a psycho-educational intervention. J Adv Nurs. 2010;66(3):673-682. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Spectrum of Topics for the Third Edition of the CHEST Cough Guidelines
a 

While cough due to many conditions such as asthma and aspiration will be discussed in the chronic category, these conditions can present acutely and subacutely. Nevertheless, the same principles of management apply once the diagnosis is made.

References

Irwin RS. Cough.. In:Irwin RS, Curley FJ, Grossman RF., eds. Symptoms of the Respiratory Tract. Armonk, NY: Futura Publishing Co, Inc; 1997:1-54.
 
Smith JA, Earis JE, Woodcock AA. Establishing a gold standard for manual cough counting: video versus digital audio recordings. Cough. 2006;2:6. [CrossRef] [PubMed]
 
Loudon RG. Cough in health and disease. Aspen Emphysema Conf. 1967;10:41-53. [PubMed]
 
Sumner H, Woodcock A, Kolsum U, et al. Predictors of objective cough frequency in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2013;187(9):943-949. [CrossRef] [PubMed]
 
Schultz DD, Olivas GS. The use of cough cardiopulmonary resuscitation in clinical practice. Heart Lung. 1986;15(3):273-282. [PubMed]
 
Jafary FH. Cough-assisted maintenance of perfusion during asystole. Can J Cardiol. 2008;24(10):e76. [CrossRef] [PubMed]
 
Irwin RS, Baumann MH, Bolser DC, et al. Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1_suppl):1S-23S. [CrossRef] [PubMed]
 
Irwin RS, Boulet L-P, Cloutier MM, et al. Managing cough as a defense mechanism and as a symptom: a consensus panel report of the American College of Chest Physicians. Chest. 1998;114(2_suppl):133S-181S. [CrossRef] [PubMed]
 
Gibson PG, Chang AB, Glasgow NJ, et al; CICADA. CICADA: Cough in children and adults: diagnosis and assessment. Australian cough guidelines summary statement. Med J Aust. 2010;192(5):265-271. [PubMed]
 
Leconte S, Paulus D, Degryse J. Prolonged cough in children: a summary of the Belgian primary care clinical guideline. Prim Care Respir J. 2008;17(4):206-211. [CrossRef] [PubMed]
 
[II Brazilian guidelines for the management of chronic cough]. J Bras Pneumol. 2006;32(suppl 6):S403-446. [CrossRef] [PubMed]
 
Asthma Workgroup, Chinese Society, Respiratory, Diseases (CSRD), Chinese Medical, Association. The Chinese national guidelines on diagnosis and management of cough (December 2010). Chin Med J (Engl). 2011;124(20):3207-3219. [PubMed]
 
Kardos P, Berck H, Fuchs KH, et al; German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough. Guidelines of the German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough. Pneumologie. 2010;64(11):701-711. [CrossRef] [PubMed]
 
Morice AH, McGarvey L, Pavord I, et al. Recommendations for the management of cough in adults. Thorax. 2006;61(suppl 1):i1-24. [CrossRef] [PubMed]
 
Wee B, Browning J, Adams A, et al. Management of chronic cough in patients receiving palliative care: review of evidence and recommendations by a task group of the Association for Palliative Medicine of Great Britain and Ireland. Palliat Med. 2012;26(6):780-787. [CrossRef] [PubMed]
 
Verlee L, Verheij TJ, Hopstaken RM, Prins JM, Salomé PL, Bindels PJ. Summary of NHG practice guideline ‘Acute cough’ [in Dutch]. Ned Tijdschr Geneeskd. 2012;156(0):A4188. [PubMed]
 
Kohno S, Ishida T, Uchida Y, et al. The Japanese Respiratory Society guidelines for management of cough. Respirology. 2006;11(suppl 4):S135-186. [PubMed]
 
English RG, Bateman ED, Zwarenstein MF, et al. Development of a South African integrated syndromic respiratory disease guideline for primary care. Prim Care Respir J. 2008;17(3):156-163. [CrossRef] [PubMed]
 
Plaza V, Miguel E, Bellido-Casado J, Lozano MP, Ríos L, Bolíbar I. Usefulness of the Guidelines of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) in identifying the causes of chronic cough [in Spanish]. Arch Bronconeumol. 2006;42(2):68-73. [CrossRef] [PubMed]
 
Britt H, Miller G, Henderson J, et al. General Practice Activity in Australia 2011-12: General Practice Series No.31. Sydney, Australia: University of Press; 2012.
 
Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey: 2010 outpatient department summary tables. 2013. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010_opd_web_tables.pdf. Accessed July 30, 2013.
 
Fujimura M. Frequency of persistent cough and trends in seeking medical care and treatment-results of an internet survey. Allergol Int. 2012;61(4):573-581. [CrossRef] [PubMed]
 
Ford AC, Forman D, Moayyedi P, Morice AH. Cough in the community: a cross sectional survey and the relationship to gastrointestinal symptoms. Thorax. 2006;61(11):975-979. [CrossRef] [PubMed]
 
The Nielsen Company (US), LLC. Market surveys for over the counter cough and cold products [unpublished survey created for Richard S. Irwin, MD]. The Nielsen Company website. http://www.nielsen.com/us/en.html. Published 2013. Accessed April 15, 2013.
 
Lewis SZ, Diekemper R, Ornelas J, Casey KR. Methodologies for the development of CHEST guidelines and expert panel reports. Chest. 2014;146(1):182-192. [CrossRef] [PubMed]
 
Diekemper R, Lewis SZ, French C, Gold P, Irwin R. Methodologies for the development of the management of cough: CHEST guideline and expert panel report. Chest. In press.
 
Metersky ML, Nathanson I. Introducing the future of ACCP clinical practice guidelines. Chest. 2012;141(2):285-286. [CrossRef] [PubMed]
 
Bellg AJ, Borrelli B, Resnick B, et al; Treatment Fidelity Workgroup of the NIH Behavior Change Consortium. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. 2004;23(5):443-451. [CrossRef] [PubMed]
 
Song MK, Happ MB, Sandelowski M. Development of a tool to assess fidelity to a psycho-educational intervention. J Adv Nurs. 2010;66(3):673-682. [CrossRef] [PubMed]
 
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