Recent educational interventions for improvement of asthma medication adherence

Poor adherence to asthma medication treatment is a dilemma as it decreases the chance of achieving and maintaining a proper asthma control. Another dilemma is that there seems to be a small range of functional interventions that enhance adherence to long-term medication treatments. The aim was to review the last five years of published educational interventions for improving adherence to asthma medication. Through systematic database searches 20 articles were identified, which matched the inclusion criteria and described educational interventions to improve asthma self-management including adherence. The current review showed that addressing unintentional non-adherence in terms of incorrect inhaler technique by recurrent education improved the technique among many patients, but not among all. Phoning patients, as a means to remove medication beliefs as adherence barriers, seemed to be an effective educational strategy, shown as increased adherence. Involving patients in treatment decisions and individualising or tailoring educational support also seemed to have favourable effect on adherence. To conclude, addressing specific adherence barriers such as poor inhaler technique or medication beliefs could favour adherence. To change adherence behavior, the current review proposes that educational adherence support should be a collaborative effort between the patient and the health-care professional based on each individual patient's needs and patient factors, including elements such as personality traits.

Related papers:

title: Adherence to anti-inflammatory treatment for asthma in clinical practice in France.
abstract: This study evaluated adherence to anti-inflammatory controller medication for asthma in a French population.



This was an observational cohort study that employed data from the health insurance database for the Aquitaine region of France. Eligible subjects were aged between 15 and 45 years and had > or = 1 reimbursement claim for anti-inflammatory controller medication between December 1, 2003, and December 31, 2003. Data were collected from June 1, 2003, to May 28, 2005. New users were defined as those having no reimbursement claim for any asthma controller medication in the 6 months preceding the index date; all others were considered previous users. All subjects were followed for 17 months. Continuous multiple-interval measures of medication availability and medication gaps, treatment persistence, and time to first renewal were calculated for users of inhaled corticosteroids (ICS) alone, users of ICS combined with a long-acting beta2-agonist (LABA) in a single inhaler (ICS/LABA) or in separate inhalers (ICS + LABA), and users of oral leukotriene antagonists.



The study population contained 12,502 new and previous users of anti-inflammatory controller medication for asthma. Their mean (SD) age was 32.0 (8.9) years and 58.3% were female. Previous users had better adherence to treatment than new users with respect to all measures. Adherence was best in previous users of leukotriene antagonists. However, only 40.2% of previous users of leukotriene antagonists had sufficient medication (95% CI, 37.6-42.9), compared with 56.8% of previous users of ICS + LABA (95% CI, 50.7-62.8), 65.5% of previous users of ICS only (95% CI, 63.1-67.9), and 69.8% of previous users of ICS/LABA (95% CI, 68.2-71.4). The rate of persistence over a 1-year period was 44.3% for previous users of leukotriene antagonists (95% CI, 41.7-46.8), compared with 27.1% for previous users of ICS only (95% CI, 25.1-29.1), 32.1% for previous users of ICS/LABA (95% CI, 30.5-33.6), and 44.1% for previous users of ICS + LABA (95% CI, 38.2-50.0).



Adherence to treatment was poor (< or = 44%) in these users of anti-inflammatory controller medications for asthma.

title: The prevalence of nonadherence in difficult asthma.
abstract: With the advent of new and expensive therapies for severe refractory asthma, targeting the appropriate patients is important. An important issue is identifying nonadherence with current therapies. The extent of nonadherence in a population with difficult asthma has not been previously reported.



To examine the prevalence of nonadherence to corticosteroid medication in a population with difficult asthma referred to a Specialist Clinic and to examine the relationship of poor adherence to asthma outcome.



General practitioner prescription refill records for the previous 6 months for inhaled combination therapy and short-acting beta-agonists were compared with initial prescriptions and expressed as a percentage. Blood plasma prednisolone and cortisol assay levels were used to examine the utility of these measures in assessing adherence to oral prednisolone. Patient demographics, hospital admissions, lung function, oral prednisolone courses, and quality of life data were analyzed to indentify the variables associated with reduced medication adherence.



A total of 182 patients were assessed. Sixty-three patients (35%) filled 50% or fewer inhaled medication prescriptions; 88% admitted poor adherence with inhaled therapy after initial denial. Twenty-one percent of patients filled more than 100% of presciptions, and 45% of subjects filled between 51 and 100% of prescriptions. Twenty-three of 51 patients (45%) prescribed oral steroids were found to be nonadherent.



A significant proportion of patients with difficult-to-control asthma remained nonadherent to corticosteroid therapy. Objective surrogate and direct measures of adherence should be performed as part of a difficult asthma assessment and are important before prescibing expensive novel biological therapies.

title: Adherence to Prescribed Treatment for Asthma: Evidence from Pharmacy Benefits Data
abstract: Failure to use asthma controller medications as prescribed is associated with more asthma-related adverse events. Medication utilization may vary with ease of drug administration, efficacy, and tolerability as well as other factors. We hypothesized that in usual-care clinical practice settings, there would be greater adherence to oral controller than to inhaled controller asthma medications.  We compared adherence to newly initiated asthma controller therapy among patients initiating monotherapy with leukotriene receptor antagonists (LTRAs), inhaled corticosteroids (ICS), or inhaled long-acting β-agonists (ILBA) from 03 1998 to 07 1999. We measured adherence as the sum of drug supply days between first and last fill dates divided by length of drug therapy. Analyses were stratified by the number of short-acting β-agonists (SBA) prescriptions per year to control for disease severity.  Pharmacy claims data from 48,751 subjects (6 to 55 years) were analyzed (mean age 30.4 years; 56% female). Mean adherence to new start monotherapy on LTRA was 67.7%, to ICS was 33.8%, and to ILBA was 40.0%. Adherence to all three controller agents increased with increasing SBA use. The percent of patients persistent to asthma controller monotherapy at both 6 and 9 months was significantly greater among those on LTRA monotherapy than on either ICS or ILBA.  In clinical practice settings, patients initiating LTRA monotherapy have about twice the adherence as patients initiating ICS or ILBA monotherapy. Because adherence to treatment is a critical component of treatment response, it is important to consider this factor in the prescription of oral vs. inhaled asthma medications.

title: Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma.
abstract: Regular use of inhaled corticosteroids (ICSs) can improve asthma symptoms and prevent exacerbations. However, overall adherence is poor among patients with asthma.  To estimate the proportion of poor asthma-related outcomes attributable to ICS nonadherence.



We retrospectively identified 405 adults age 18 to 50 years who had asthma and were members of a large health maintenance organization in southeast Michigan between January 1, 1999, and December 31, 2001. Adherence indices were calculated by using medical records and pharmacy claims. The main outcomes were the number of asthma-related outpatient visits, emergency department visits, and hospitalizations, as well as the frequency of oral steroid use.



Overall adherence to ICS was approximately 50%. Adherence to ICS was significantly and negatively correlated with the number of emergency department visits (correlation coefficient [ R ] = -0.159), the number of fills of an oral steroid ( R = -0.179), and the total days' supply of oral steroid ( R = -0.154). After adjusting for potential confounders, including the prescribed amount of ICS, each 25% increase in the proportion of time without ICS medication resulted in a doubling of the rate of asthma-related hospitalization (relative rate, 2.01; 95% CI, 1.06-3.79). During the study period, there were 80 asthma-related hospitalizations; an estimated 32 hospitalizations would have occurred were there no gaps in medication use (60% reduction).



Adherence to ICS is poor among adult patients with asthma and is correlated with several poor asthma-related outcomes. Less than perfect adherence to ICS appears to account for the majority of asthma-related hospitalizations.

title: Adherence and persistence with fluticasone propionate/salmeterol combination therapy.
abstract: Pharmacy database medication refill studies provide a panoramic view of medication-taking behavior in patients nationally.



To investigate fluticasone propionate/salmeterol combination (FSC) adherence, including the factors associated with refill adherence in a large national pharmacy database.



Adherence and persistence were documented for 12 months from date of initial FSC prescription in 5504 patients who filled their medication at a nationwide pharmacy chain.



On average, patients filled enough medication to cover 22.2% of days. More than half the patients filled a 30-day prescription only once over the 1-year interval. Higher adherence levels were associated with being male, being older than 35 years, having a comorbid disorder, a having a copay of 1.01 dollar to 10 dollars, previous beta2-agonist use, and a prescription for higher-dose FSC.



This pharmacy database study portrays medication adherence levels to be considerably lower than those reported in most clinical trials, suggests that most adults taking FSC obtain a single fill before abandoning their controller medication, and indicates a need for a reappraisal of current treatment guidelines and educational strategies for both providers and patients.



For many patients, filling of a controller medication is markedly discrepant with practice guidelines. Reappraisal of both the guidelines and strategies to implement them is in order.

title: Interventions for enhancing medication adherence.
abstract: People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.



To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.


SEARCH STRATEGY
We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.



Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.



Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.



For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.



For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

title: Variations in Patients’ Adherence to Medical Recommendations: A Quantitative Review of 50 Years of Research
abstract: BackgroundThe literature on patient adherence to treatment includes hundreds of empirical studies. A comprehensive examination of the findings requires the organization and quantification that is possible with meta-analysis.  goals of this research are retrieval, compilation, and averaging of adherence rates in all published empirical studies from 1948 to 1998; assessment of variation according to sample characteristics, time period of publication, measurement method, disease, and regimen; and examination of the effects on adherence of patient demographic characteristics. MethodsWe calculated a meta-analysis of 569 studies reporting adherence to medical treatment prescribed by a nonpsychiatrist physician, and 164 studies providing correlations between adherence and patients’ age, gender, education, and income/socioeconomic status; group comparison and multiple regression analysis of moderators. ResultsThe average nonadherence rate is 24.8%. Controlling for intercorrelations among moderator variables, adherence is significantly higher in more recent and smaller studies and in those involving medication regimens and adult samples. The use of physical tests and self-report have respectively significant and borderline negative effects on the level of adherence, and disease severity and use of the medical record have no significant effects. Adherence is highest in HIV disease, arthritis, gastrointestinal disorders, and cancer, and lowest in pulmonary disease, diabetes, and sleep. Demographic effects on adherence are small and moderated by sample, regimen, and measurement variables. ConclusionsThis review offers insights into the literature on patient adherence, providing direction for future research. A focus on reliability and validity of adherence measurement and systematic study of substantive and methodologic moderators are recommended for future research on patient adherence.

title: Compliance, adherence, and concordance : Implications for asthma treatment
abstract: Good-quality outcomes in asthma hinge not just on the availability of medications but also on their appropriate use by patients: optimal "self-management." In asthma, low rates of adherence to prophylactic (preventer) medication are associated with higher rates of hospitalization and death. Many patients choose not to take their medication because they perceive it to be unnecessary or because they are concerned about potential adverse effects. Approximately one third of asthma patients have strong concerns about adverse effects from inhaled corticosteroids (ICS). These concerns are not just related to the experience of local symptoms attributed to ICS side effects, but also include more abstract concerns about the future, arising from the belief that regular use of ICS will result in adverse long-term effects or dependence. We need more effective ways of eliciting and addressing patients' concerns about ICS. The development of ICS options with an improved safety profile remains a key objective. However, the ideal solution is not just pharmacologic. We also need more effective ways of communicating the relative benefits and risks to patients in order to facilitate informed adherence. Clinicians must be prepared to work in an ongoing partnership with patients to ensure that they are offered a clear rationale as to why ICS are necessary and to address their concerns about potential adverse effects. This approach, based on a detailed examination of patients' perspectives on asthma and its treatment, and an open, nonjudgmental manner on the part of the clinician, is consistent with the idea of concordance.

title: Compliance in asthma.
abstract: Low rates of compliance with medication pose a major challenge to the effective management of most chronic diseases, including asthma. The high medical and social costs of non-compliance, and the apparent lack of effective methods for dealing with it, has stimulated renewed interest in this complex issue. Two broad categories of non-compliance have been identified, namely unintentional (or 'accidental') and intentional (or 'deliberate'). Unintentional non-compliance may result from poor doctor-patient communication or a lack of ability to follow advice. Intentional non-compliance occurs when the patient knows what is required but decides not to follow this to some degree. Healthcare professionals need to be aware of the various issues affecting compliance in all patients. The reasons for non-compliance are many and varied, and include factors such as complexity of the treatment regimen, administration route, patient beliefs about therapy and other psychological factors. Improvement in patient compliance with therapy will require better doctor-patient communication, improved patient education, the tailoring of therapy to the individual and possible novel strategies such as offering feedback to the patients on their level of compliance.

title: Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs).
abstract: According to guidelines, inhaler technique should be tested in all patients, particularly those with poorly controlled asthma. We aimed to assess uncontrolled asthma patients' ability to use a pressurised metered-dose inhaler (pMDI) using the Aerosol Inhalation Monitor (AIM, 
Practices invited patients for a detailed clinical review by trained asthma nurses according to practice-agreed protocols. Reviews took place from 1st April to 30th June 2008, and included checking of inhaler technique. Reasons for invitations included, time since last review, asthma control, prescriptions, adherence to medical advice. A proxy measure of control--the total number of short-acting β2-agonist (SABA) bronchodilator inhaler canisters prescribed in the previous 12 months--was used. Data on 77 pre-determined clinical parameters (including prescribing and healthcare utilisation data) were collected. Patient-completed postal symptom questionnaires (the RCP 3 questions) were obtained in some patients. All patients using pMDIs had at least two assessments using the AIM, and where appropriate inhaler technique education was provided.



2123 (24% of those invited) symptomatic asthma patients were reviewed; 1291 (61%) were using pMDIs (mean age 52 years; SD 21), of whom over 80% were in BTS/SIGN Steps 2 and 3. 1092 (85.6%) of those patients using pMDIs failed the first AIM assessment. There was a significant increase in the number of patients able to use their pMDIs correctly following instruction after the second (129 to 260 of 1197 patients, p<0.01) and third (61 to 181 of 528 patients, p< 0.01) tests. However, 78.4% and 65.7% of those tested twice and three times, respectively, failed the AIM assessment despite instruction. Logistic regression analysis failed to show any effect of age and BTS step on these outcomes.



A majority of symptomatic asthma patients in this study were unable to use pMDIs correctly. It is essential to check all patients' ability to use their prescribed inhalers regularly. Cost alone should not determine prescribing recommendations.

title: Effectiveness of pharmacist intervention for asthma control improvement
abstract: Education on optimal medication use is an essential strategy to improve asthma control. The current authors investigated whether pharmacist interventions, focused on appropriate use of asthma medication and tailor-made to the patient's current asthma control, would improve asthma control in adult patients. A 6-month randomised, controlled, parallel-group trial was conducted in 66 community pharmacies in Belgium. Patients were randomly assigned to receive usual pharmacist care (n = 94) or a pre-defined pharmacist intervention (n = 107). This intervention mainly focused on improving inhalation technique and medication adherence. Primary outcome was the level of asthma control, as assessed by the Asthma Control Test® (ACT). Mean ACT scores did not change from baseline for both study groups. However, a pre-defined subgroup analysis of patients having insufficiently controlled asthma at baseline showed that the intervention had significantly increased the ACT score after 6 months compared with usual care. The intervention also reduced, for the complete study group, reliever medication use and the frequency of night-time awakenings due to asthma. Inhalation technique and adherence to controller medication were significantly better in the intervention group. In conclusion, pragmatic community pharmacy-based programmes can significantly improve therapeutic outcomes in adult asthma patients.

title: Repeated Instruction on Inhalation Technique Improves Adherence to the Therapeutic Regimen in Asthma
abstract: Adherence to inhalation therapy is a critical determinant of the success of asthma management. Reasons for nonadherence have been well studied, but reasons for good adherence are poorly understood. Understanding the mechanisms of adherence to inhalation therapy is important in developing strategies to promote adherence. The objective of this study was to assess the factors and mechanisms that contribute to and the clinical outcomes relating to adherence to inhalation therapy.  The factors and outcomes related to adherence to inhalation therapy were examined cross-sectionally in 176 adults with asthma using a self-reported adherence questionnaire that consisted of four items dealing with the use of inhaled controller medications. A 5-point Likert scale was used for the responses to each item. Adherence was assessed based on the overall mean adherence score.  Of the 176 patients who were potential participants, 146 (83%) responded with usable information. Significant factors associated with the overall mean adherence score were older age (r = .18, p = .032) and receiving repeated instruction on inhalation techniques (p = .0016). Of the 146 respondents, 25 (17.1%) patients were given repeated verbal instruction or demonstrations of inhalation technique by a respiratory physician. On logistic regression analysis, good adherence to inhalation therapy was significantly related to the receiving of repeated instruction on inhalation technique, with an odds ratio of 2.90 (95% confidence interval 1.07–7.88; p = .037). Furthermore, less intentional nonadherent behavior was reported in patients with repeated instruction on inhalation technique compared to those without it. A significant correlation was found between the overall mean adherence score and the frequency of asthma exacerbations (r = −.19, p = .021), emergency room visits (r = −.19, p = .042), and the health-related quality of life score (St. George's Respiratory Questionnaire: Total, r = −.22, p = .024; Symptoms, r = −.21, p = .022; Impacts, r = −.20, p = .035).  Repeated instruction on inhalation techniques may contribute to adherence to inhalation therapy through decreasing intentional nonadherence. Furthermore, good adherence to the therapeutic regimen may offer good asthma-related outcomes.

title: Self-regulation and Self-management in Asthma: Exploring The Role of Illness Perceptions and Treatment Beliefs in Explaining Non-adherence to Preventer Medication
abstract: The present study was designed to evaluate the degree to which variations in reported adherence to preventer medication for asthma could be explained by two sets of beliefs: perceptions of asthma and perceptions of asthma medication (beliefs about its necessity and concerns over its use). It also begins the empirical testing of an extended self-regulatory model, which includes treatment beliefs as well as illness perceptions. Using a cross-sectional design, 100 community-based patients completed validated questionnaires assessing their perceptions of asthma, beliefs about preventer inhalers and reported adherence to them. The findings showed that non-adherent behaviours were associated with doubts about the necessity of medication and concerns about its potential adverse effects and with more negative perceived consequences of illness. A hierarchical linear regression analysis revealed that socio-demographic and clinical factors explained only a small amount of variance in adherence whereas illness perceptions and treatment beliefs were both more substantial independent predictors. The best fit Amos analysis showed that illness perceptions influenced adherence both directly and indirectly via treatment beliefs, which, in turn, were the strongest predictors. The findings lend preliminary support for an extended self-regulatory model of treatment adherence, which incorporates beliefs about treatment as well as illness perceptions.

title: The Patient's Perspective: Adherence or Non-adherence to Asthma Controller Therapy?
abstract: Adherence with controller therapy poses a major challenge to the effective management of persistent asthma. The aim of this study was to explore the patient-related aspects of adherence among adult asthmatics.  The participants (n = 509 adult asthmatics), recruited from all parts of Denmark, answered the questionnaire concerning asthma knowledge, attitudes, adherence, and treatment through the Internet.  A total of 67% of the patients were prescribed inhaled corticosteroids (ICS). However, according to Global Initiative for Asthma (GINA)-guidelines' symptom severity classification, 85% should have been on ICS. Accidental and intentional non-adherence with ICS at least twice a week was reported by 27% and 24%, respectively. In case of deterioration, 60% of the patients preferred to take more reliever medication, instead of increasing the ICS dose. Having a fixed daily routine with regard to medication and following the advice given by their doctor were the main reasons for adherence, whereas lack of perceived symptoms was the main reason for non-adherence. Non-adherence was associated with increasing disagreement with the statements that controller therapy is effective (p < 0.04), as well as an essential part of asthma therapy (p < 0.002).  Both accidental and intentional non-adherence with controller therapy is common among adult asthmatics. The reasons for suboptimal adherence seem to be accessible through education of both patients and caregivers.

title: Beliefs about medicines predict refill adherence to inhaled corticosteroids.
abstract: Despite the importance of the chronic use of inhaled corticosteroids (ICS) in maintaining asthma control, reported adherence varies between 40% and 60%. The Beliefs about Medicines Questionnaire (BMQ) has been shown to correlate with self-reported adherence. The aim of this study is to investigate whether beliefs about ICS (necessity and concerns), as measured by the BMQ, relate to adherence objectively measured by prescription-refill records.



In a cross-sectional study of patients aged 18-45 years who filled at least two ICS prescriptions in 11 community pharmacies in The Netherlands, perceptions of ICS were assessed using the BMQ. Additionally, self-reported adherence was assessed using the Medication Adherence Report Scale. ICS prescription-refill adherence rates for a 12-month period prior to the survey were obtained from automated pharmacy dispensing records. Four attitudinal groups were defined using the necessity and concerns constructs. Statistical tests were used to examine associations between ICS adherence (assessed by subjective self-report and objective pharmacy records), specific beliefs about and attitudes towards ICS, and more general beliefs about pharmaceuticals.



Questionnaires were returned by 238 patients (51.1%). Both self-reported adherence (r=.38) and adherence by pharmacy records (rho=0.32) correlated with ICS necessity beliefs and concerns. Patients defined as skeptical, indifferent, ambivalent, or accepting, on the basis of these constructs, differed with respect to both their attitudes towards medicines in general and their adherence to medication.



Patients' beliefs about ICS correlate not only with adherence by self-report but also with a more objective measure of medication adherence calculated by pharmacy dispensing records. The necessity-concerns constructs offer a potentially useful framework to help clinicians elicit key treatment beliefs influencing adherence to ICS.

title: Beliefs About Asthma Medications: Patients Perceive Both Benefits and Drawbacks
abstract: Patients have diverse beliefs about asthma medications that may be influenced by asthma characteristics. The objective of this qualitative analysis was to identify patients' beliefs about asthma medications and to assess these beliefs according patient and asthma characteristics, including asthma severity and patient-reported medication adherence. From interviews with 52 patients (mean age 43 years, 87% women, 71% taking maintenance medications), 17 categories of beliefs about medications were discerned which were grouped into perceived benefits (e.g., permit activities, thwart symptoms) and perceived drawbacks (e.g., establish a medication routine, ensure supply). Beliefs were not mutually exclusive, with 56% of patients citing both benefits and drawbacks. Beliefs did not differ based on asthma severity or type of current therapy, however, patients who cited drawbacks were more likely to have worse self-reported Morisky Medication Adherence Questionnaire scores (possible range 0–4, higher is worse adherence) compared to those who did not cite drawbacks (1.9 ± 1.3 vs 0.9 ± 0.9; p =. 02). Providers should be aware of patients' beliefs about medications in order to reinforce perceived benefits and address perceived drawbacks.

title: Treating asthma with a self-management model of illness behaviour in an Australian community pharmacy setting.
abstract: Asthma affects a considerable proportion of the population worldwide and presents a significant health problem in Australia. Given its chronic nature, effective asthma self-management approaches are important. However, despite research and interventions targeting its treatment, the management of asthma remains problematic. This study aimed to develop, from a theoretical basis, an asthma self-management model and implement it in an Australian community pharmacy setting in metropolitan Sydney, using a controlled, parallel-groups repeated-measures design. Trained pharmacists delivered a structured, step-wise, patient-focused asthma self-management program to adult participants over a 9-month period focusing on identification of asthma problems, goal setting and strategy development. Data on process- clinical- and psychosocial-outcome measures were gathered. Results showed that participants set an average of four new goals and six repeated goals over the course of the intervention. Most common goal-related themes included asthma triggers, asthma control and medications. An average of nine strategies per participant was developed to achieve the set goals. Common strategies involved visiting a medical practitioner for review of medications, improving adherence to medications and using medications before exercise. Clinical and psychosocial outcomes indicated significant improvements over time in asthma symptom control, asthma-related self-efficacy and quality of life, and negative affect. These results suggest that an asthma self-management model of illness behaviour has the potential to provide patients with a range of process skills for self-management, and deliver improvements in clinical and psychosocial indicators of asthma control. The results also indicate the capacity for the effective delivery of such an intervention by pharmacists in Australian community pharmacy settings.

title: The Madison Avenue effect: how drug presentation style influences adherence and outcome in patients with asthma.
abstract: Little is known about how drug presentation influences medication adherence.



To examine the effect of an educational program aimed at increasing expectations of treatment benefit on medication adherence.



Data are analyzed from 99 participants who underwent electronic drug monitoring during the Trial of Asthma Patient Education, a randomized, placebo-controlled, multicenter trial. Participants with suboptimally controlled asthma were randomized to placebo or montelukast in conjunction with a presentation mode that was either neutral or designed to increase outcome expectancy. Adherence was monitored electronically over 4 weeks and was defined as ≥ 80% use of prescribed doses. Outcome expectancy, peak expiratory flow, prebronchodilator FEV₁, asthma control (Juniper asthma control questionnaire), and asthma-related quality of life were assessed at baseline and at the 4-week follow-up.



Average electronic medication adherence was 69.9%. There was a significant interaction between presentation mode and drug assignment, with participants in the enhanced/montelukast group having a higher change in outcome expectancy (Δ 2.1 points; P < .001) and better medication adherence (odds ratio, 4.0; 95% CI, 1.1-14.3) compared with those in the neutral/placebo group. There was no difference in asthma symptoms, quality of life, or clinical outcomes on the basis of presentation mode. Rather, increased outcome expectancy was associated with modest improvements in asthma symptoms after adjusting for presentation mode, drug assignment, and medication adherence.



The use of an enhanced presentation aimed at increasing outcome expectancy may lead to improved medication adherence.

title: The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines
abstract: This “proof of concept” study aimed to assess the cost effectiveness of pharmacists giving advice via telephone, to patients receiving a new medicine for a chronic condition, in England.  The self-regulatory model (SRM) theory was used to guide development of our intervention and used in training pharmacists to adopt a patient-centred approach. Non-adherence to new medicines for chronic conditions develops rapidly so we developed a study intervention in which a pharmacist telephoned patients two weeks after they had started a new medicine for a chronic condition. Patients were included if they were 75 or older, or were suffering from stroke, cardiovascular disease, asthma, diabetes or rheumatoid arthritis, and were randomized into treatment or control arms. Main outcome measures were non-adherence and cost to the UK NHS, obtained via a questionnaire sent two months after starting therapy. Cost of the intervention was also included. Incremental cost effectiveness ratios (ICERs) were generated.  Five hundred patients were recruited. At 4-week follow-up, non-adherence was significantly lower in the intervention group (9% vs 16%, p = 0.032). The number of patients reporting medicine-related problems was significantly lower in the intervention group compared to the control, (23% vs 34% p = 0.021). Mean total patient costs at 2-month follow-up (median, range) were intervention: £187.7 (40.6, 4.2–2484.3); control: £282.8 (42, 0–3804) (p < 0.0001). The intervention was dominant (less costly and more effective). If the decision maker is not willing to pay anything for one extra adherent patient, there is still a 90% probability that the intervention is cost effective.  These findings suggest that pharmacists can meet patients’ needs for information and advice on medicines, soon after starting treatment. While a larger trial is needed to confirm that the effect is real and sustained, these initial findings suggest the study intervention may be effective, at least in the short term, with a reduced overall cost to the health provider.

title: Impact of an Adherence Intervention Program on Medication Adherence Barriers, Asthma Control, and Productivity/Daily Activities in Patients With Asthma
abstract: This study evaluated the impact of an asthma patient intervention program, with a focus on medication adherence on adherence barriers, asthma control, and productivity/daily activities.  Patients ≥18 years old who were employed by a large Southeastern public school system, had ≥1 medical claim for asthma, and were taking ≥1 asthma medication were invited to participate in the study. The ASK-20, the Asthma Control Test (ACT), and a productivity questionnaire were administered before and after a 6-month period of intervention that involved the use of baseline ASK-20 results to create patient-specific reports on adherence barriers and talking points for care managers to use during the two outbound telephone calls addressing barriers identified. Patients also received three educational mailings. The ASK-20 is a brief, self-reported instrument developed to identify patient-specific barriers to medication adherence and to improve provider/patient communication about adherence.  Of 112 individuals who enrolled, 87 completed the program (77.7%). Participants' mean age was 48.2 years (SD = 10.5), and most were female (86.2%) and white (64.4%). The mean number of years with asthma was 17.5 (SD = 14.7); approximately one third (36.8%) of participants had had asthma for >20 years. The intervention was associated with a significant reduction in the number of adherence barriers (3.8 to 2.8; p = .0021) as well as improvement in asthma control as reflected in an increase in the percentage of participants with controlled asthma defined as having an ACT score > 19 (50.0% to 64.6%; p = .0285). Significant reductions in the mean number of days that housework or schoolwork was limited by asthma (p = .0059) and the mean number of days that family, social, or recreational activities were missed or limited because of asthma (p = .0185) were also observed. The majority of the participants (95%) rated the program as being good, very good, or excellent.  Programs incorporating a clinical assessment tool such as the ASK-20 for identifying a broad range of risk factors for nonadherence and for developing patient-specific intervention may reduce adherence barriers and improved disease control and ability to perform daily activities in patients with asthma.

title: Test of an Interactive Voice Response Intervention to Improve Adherence to Controller Medications in Adults with Asthma
abstract: This study was conducted to test the effectiveness of a theory-based interactive voice response (IVR) intervention to improve adherence to controller medications among adults with asthma.  Fifty participants aged 18 to 65 years who had a physician diagnosis of asthma and a prescription for a daily inhaled corticosteroid, attended a baseline visit and a final visit 10 weeks later. Participants randomized to the intervention group received 2 automated IVR telephone calls separated by one month, with one additional call if they reported recent symptoms of poorly controlled disease or failure to fill a prescription. Calls were completed in less than 5 minutes and included content designed to inquire about asthma symptoms, deliver core educational messages, encourage refilling of inhaled corticosteroid prescriptions, and increase communication with providers. Adherence was tracked during 10 weeks, with objective measures that included either electronic monitors or calculation of canister weight. Participants completed the Asthma Quality of Life Questionnaire, the Asthma Control Test, and the Beliefs in Medications Questionnaire (BMQ) during both visits.  Adherence was 32% higher among patients in the IVR group than those in the control group (P = .003). A more favorable shift in perception of inhaled corticosteroids was seen on BMQ scores of patients in the IVR group (P = .003), which in turn correlated with degree of adherence change (r = 0.342; P = .0152). No differences emerged for the Asthma Quality of Life Questionnaire or Asthma Control Test.  The IVR intervention resulted in a significant increase in adherence to inhaled corticosteroid treatment and improved BMQ scores during the study interval. The association of increased adherence with increased BMQ scores suggests that the intervention succeeded in helping participants adopt a more favorable perception of their controller medication, leading in turn to improved adherence.

title: Asthma patients' self-reported behaviours toward inhaled corticosteroids.
abstract: Patient adherence to recommended use of ICS is questionable in asthma, with irregular use or interruptions occurring frequently. Factors explaining discontinuation of controller therapy could orientate interventions. The characteristics of patients with interruptions of inhaled corticosteroids (ICSs), intentional or accidental, were investigated.



Asthma patients regularly prescribed ICS by GPs (Cegedim network) were included. Patients' characteristics and behaviours toward ICS (accidental/intentional interruptions, less frequent use of ICS and change in dosing) were identified from self-report questionnaires, and linked to data prescription database. Interrelations between declared behaviours toward ICS were studied with a Multiple Component Analysis (MCA) and the correlates of ICS interruptions were identified.



During the past 3 months, 31.6% of 204 patients (mean age: 53.8 years, females: 59.3%) intentionally interrupted ICS when feeling better, 25.4% forgot ICS and 18.3% deliberately changed the doses. A quarter of patients considered constant use of respiratory medicines as unhealthy. MCA revealed that intentional, accidental interruptions and less frequent use of ICS were closely correlated. Risk of intentional interruption was increased when patients considered constant use of respiratory therapy to be unhealthy (OR=3.36, 95%CI=[1.47-7.66]). Conversely, risk was significantly lower when ICS was associated or combined with another controller (OR=0.24, 95%CI=[0.08-0.73]), compared to ICS in monotherapy. Less frequent interruptions were observed in patients older than 65 (OR=0.35, 95%CI=[0.13-0.89]).



Our study suggests that discontinuation of use of controllers is associated with other inadequate behaviours or beliefs about inhaled controllers. Efforts should be targeted at patients' perceptions and behaviours toward controller therapy.

title: Factors influencing patient decisions about the use of asthma controller medication.
abstract: Patient nonadherence with asthma controller medication is pervasive and impedes successful adoption of national treatment guidelines.



To survey adult patients with asthma about the factors influencing their decisions about when to use their asthma controller medications.



Two hundred adults with asthma were randomly selected from a national database and were surveyed by telephone about medication use, barriers to adherence, and treatment preferences.



Adherence to daily controller medication in the group was generally well below the prescribed level despite the fact that many had relatively severe asthma and inadequately controlled symptoms. Thirty percent of the respondents indicated that they had been instructed by their physician to use their controller medication intermittently as guided by their symptoms. Most respondents expressed a desire to be more in control of their treatment and for that treatment to be more immediately effective and long-lasting but did not perceive inadequate information to be a barrier to adherence.



These insights into patient perception and motivation suggest the importance of developing treatment plans that allow patients some degree of control over medication use.

title: Participatory Decision Making, Asthma Action Plans, and Use of Asthma Medication: A Population Survey
abstract: Use of controller asthma medication and possession of asthma action plans remains suboptimal. Our aim was to investigate the association of the propensity of physicians to involve patients in their care (participatory decision-making style) and their asthma management in a representative population sample of 3015 adults. Current doctor-diagnosed asthma was reported by 393 (13.0%). People who rated their doctors as more participatory were significantly more likely to report more regular use of controller medications and possession of a written asthma action plan, but not less asthma morbidity. Possession of a written action plan was associated with more participatory interactions (OR 2.3; 95% CI 1.1–4.7, for upper tertile scores compared to lowest tertile); more severe symptoms (OR 4.8; 95% CI 1.7–13.0), being female (OR 2.2; 95% CI 1.2–4.3), those with higher education, and residence outside the metropolitan area (OR 2.1; 95% CI 1.1–4.0). Increasing patient participation in their own care is associated with better asthma management, independent of asthma symptoms. Longitudinal studies are needed to examine if increasing participation in decisions can also improve asthma outcomes.

title: A study of a multi-level intervention to improve non-adherence in difficult to control asthma.
abstract: Difficult to control asthma accounts for significant morbidity and healthcare cost, and non-adherence to medication is a common cause. It remains unclear if targeting non-adherence in this population improves healthcare outcomes.



All subjects were referred to a Specialist Difficult Asthma Service (60% from Respiratory physicians); poor adherence was identified using prescription refill records for inhaled combination therapy. A sequential 2 phase study examined the effect of identifying and targeting non-adherence to inhaled long-acting β-agonist/inhaled steroid combination therapy; phase 1 - an observational study utilising objective measures of non-adherence to facilitate a medical concordance discussion followed by phase 2, a 12 month prospective single blind randomised controlled trial where subjects with persistent poor adherence were randomised to a nurse-led menu driven intervention.



A total of 239 patients were assessed; 31 of 83 subjects (37%) who were initially non-adherent, significantly improved adherence after concordance interview, with reduced prescribed daily dose of ICS (data p<0.001), rescue prednisolone courses (data, p<0.001) and hospital admissions (data, p=0.006). With the menu driven intervention, adherence also improved (intervention 37.6% to 61.9%, control group 31.7% to 28.8%) with reduced maintenance oral steroid dose in subjects on maintenance steroids.



Poor adherence in difficult-to control asthma is common, but when identified and targeted can be improved and this is associated with large improvements in important healthcare outcomes. Previous nihilism towards non-adherence in this population is not supported by this study.

title: Problem solving to improve adherence and asthma outcomes in urban adults with moderate or severe asthma: a randomized controlled trial.
abstract: Improving inhaled corticosteroid (ICS) adherence should improve asthma outcomes.



In a randomized controlled trial we tested whether an individualized problem-solving (PS) intervention improves ICS adherence and asthma outcomes.



Adults with moderate or severe asthma from clinics serving urban neighborhoods were randomized to PS (ie, defining specific barriers to adherence, proposing/weighing solutions, trying the best, assessing, and revising) or standard asthma education (AE) for 3 months and then observed for 3 months. Adherence was monitored electronically. Outcomes included the following: asthma control, FEV(1), asthma-related quality of life, emergency department (ED) visits, and hospitalizations. In an intention-to-treat-analysis longitudinal models using random effects and regression were used.



Three hundred thirty-three adults were randomized: 49 ± 14 years of age, 72% female, 68% African American, 7% Latino, mean FEV(1) of 66% ± 19%, and 103 (31%) with hospitalizations and 172 (52%) with ED visits for asthma in the prior year. There was no difference between groups in overall change in any outcome (P > .20). Mean adherence (61% ± 27%) decreased significantly (P = .0004) over time by 14% and 10% in the AE and PS groups, respectively. Asthma control improved overall by 15% (P = .002). In both groups FEV(1) and quality of life improved by 6% (P = .01) and 18% (P < .0001), respectively. However, the improvement in FEV(1) only occurred during monitoring but not subsequently after randomization. Rates of ED visits and hospitalizations did not significantly decrease over the study period.



PS was not better than AE in improving adherence or asthma outcomes. However, monitoring ICS use with provision of medications and attention, which was imposed on both groups, was associated with improvement in FEV(1) and asthma control.

title: Unmet needs in asthma: Global Asthma Physician and Patient (GAPP) Survey: global adult findings
abstract: The Global Asthma Physician and Patient (GAPP) Survey is the first global quantitative survey designed to uncover asthma attitudes and treatment practices among separate groups of physicians and patients, with the goal of identifying barriers to optimal management.

title: Shared treatment decision making improves adherence and outcomes in poorly controlled asthma.
abstract: Poor adherence to asthma controller medications results in poor treatment outcomes.



To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care.



In shared decision making (SDM), nonphysician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making, treatment was prescribed without specifically eliciting patient goals/preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters.



Refill adherence was measured using continuous medication acquisition (CMA) indices-the total days' supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister equivalents. In follow-up Year 1, compared with usual care, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.46; P < 0.0001) and long-acting beta-agonist adherence (CMA, 0.51 vs. 0.40; P = 0.0225); higher cumulative controller medication dose (canister equivalent, 10.9 vs. 5.2; P < 0.0001); significantly better clinical outcomes (asthma-related quality of life, health care use, rescue medication use, asthma control, and lung function). In Year 2, compared with usual care, SDM resulted in significantly lower rescue medication use, the sole clinical outcome available for that year. Compared with clinician decision making, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.59; P = 0.03) and long-acting beta-agonist adherence (CMA, 0.51 vs. 0.41; P = 0.0143); higher cumulative controller dose (CMA, 10.9 vs. 9.1; P = 0.005); and quantitatively, but not significantly, better outcomes on all clinical measures.



Negotiating patients' treatment decisions significantly improves adherence to asthma pharmacotherapy and clinical outcomes.

title: Objective airway monitoring improves asthma control in the cold and flu season: a cluster randomized trial.
abstract: The goals of asthma care are reductions in risk and impairment, but achieving these goals requires collaborative work between patients and their clinicians. The purpose of this study was to improve inhaled corticosteroid (ICS) adherence and asthma control by cueing therapeutic communication between patients with asthma and their primary care clinicians.



We conducted a prospective, cluster-randomized, controlled effectiveness trial to assess the effect of providing visually standardized, interpreted peak flow graphs (CUE intervention) to patients and their clinicians on ICS adherence and asthma control. Asthma control outcomes were analyzed by season to account for seasonal variations in exacerbation frequency.



Although mean log-transformed ICS adherence was not significantly different between the two groups, there was a trend toward preserved adherence in the intervention group over time (P = .16). Intervention patients required fewer courses of oral steroids during winter (9% vs 23%, P < .001) and spring (3% and 17%, P < .001) compared with control subjects. Intervention patients also had fewer periods of worsening symptoms (65% vs 89%, P < .001) and fewer urgent care visits (10% vs 23%, P < .001) during winter compared with control subjects. Post hoc analysis showed significant improvement in the intervention group with respect to ICS adherence during winter months (P < .05), the likely explanation for the reduction in prednisone use and symptoms. Day-to-day peak flow variability in the intervention group fell consistently throughout the study from an average of 32% at baseline to 23% at final measurement (P < .001), indicating less airway reactivity over time.



Our findings provide evidence of the value of peak flow monitoring for patients with asthma during seasons of greatest vulnerability, the cold/flu season. The peak flow information apparently led to improvements in ICS adherence resulting in less need for prednisone rescue and fewer episodes of worsening symptoms.

title: The Effects of a Disease Management Program on Self-Reported Health Behaviors and Health Outcomes: Evidence From the “Florida: A Healthy State (FAHS)” Medicaid Program
abstract: Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of 15,275 patients with one or more chronic illnesses (congestive heart failure, hypertension, diabetes, or asthma) was undertaken. Control of hypertension improved from baseline to Year 1 (adjusted odds ratio = 1.60, p < .05), with maintenance at Year 2. Adjusted cholesterol declined by 6.41 mg/dl from baseline to Year 1 and by 12.41 mg/dl (p < .01) from baseline to Year 2. Adjusted average medication compliance increased by 0.19 points (p < .01) in Year 1 and 0.29 points (p < .01) in Year 2. Patients in the disease management program benefited in terms of controlling hypertension, asthma symptoms, and cholesterol and blood glucose levels.

title: Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community
abstract: Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design.  Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.  186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from “severe” to “not severe” than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference −149.11 μg, 95% CI −283.87 to −14.36; p = 0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting β agonist (OR 3.80, 95% CI 1.40 to 10.32; p = 0.01) and improved scores on risk of non-adherence (difference −0.44, 95% CI −0.69 to −0.18; p = 0.04), quality of life (difference −0.23, 95% CI −0.46 to 0.00; p = 0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference −1.39, 95% CI −2.44 to −0.35; p<0.01). No significant change in spirometric measures occurred in either group.  A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.

title: Interactive Small-Group Asthma Education in the Community Pharmacy Setting: A Pilot Study
abstract: This study aimed to compare the effects of two small-group asthma education interventions (one delivered by specially trained pharmacists (group A) and one delivered by a pharmacist researcher trained as an asthma educator (group B)) with usual care provided by community pharmacists (group C) on clinical and humanistic outcomes for people with asthma.  Pharmacies were randomly selected to provide either group A, B, or C interventions. Data were collected at baseline, post intervention (groups A and B) and at 6 and 12 weeks (final visit).  Forty-eight people with asthma were recruited into groups A (n = 16), B (n = 16), and C (n = 16) and there were no significant differences between the groups at baseline. At 12 weeks there was a significant decrease in the proportion of patients with severe asthma/poor control in groups A and B compared with group C (56%, 44% and 50% to 25%, 13% and 50% [n = 48, p < 0.05], respectively). In Groups A and B, the proportion of patients with optimal metered dose inhaler (MDI) technique improved from 9% and 14%, respectively, at baseline to 82% and 93% (n = 11, p = 0.02, n = 14, p < 0.001), respectively, at 12 weeks. The proportion of patients with optimal dry powder inhaler (DPI) technique improved in Groups A and B from 0% and 8%, respectively, at baseline to 86% and 92% (n = 7, p < 0.001; n = 13, p = 0.002), respectively, at 12 weeks. No change in inhaler technique was observed for Group C. There were significant improvements in asthma knowledge scores in Groups A and B compared to Group C over time.  Small-group asthma education delivered by pharmacists appears to be more effective than usual care in improving clinical and humanistic asthma outcomes.

title: Clinical pharmacist counseling improves outcomes for Taiwanese asthma patients
abstract: To assess the impact of an asthma educational program provided by a nurse combined with asthma counseling provided by a pharmacist on asthma knowledge, quality of life and clinical outcomes in Taiwanese patients with asthma.  All patients were recruited from Pulmonary Medicine outpatient clinic, the Tri-Service General Hospital, Taipei, Taiwan. Asthma education was given in three one-hour sessions offered during monthly clinic visits.  A total of 91 asthma patients were randomly assigned to a nurse-administered education program (Group 1), the education program with additional pharmacist counseling (Group 2), or a control group receiving routine care only (control). Three questionnaires were used for assessment at months 0, 3 and 6. Outcomes were compared between groups to determine efficacy.  Asthma knowledge, health-related quality of life, and medication adherence were measured at baseline and 3 and 6 months after enrollment.  A total of 104 patients were enrolled; 91 completed the study. Knowledge scores of patients in Groups 1 and 2 increased significantly compared to control group. Both intervention groups showed significant increases in knowledge scores with longer follow-up. Group 2 showed a significant improvement in clinical symptoms between baseline (month 0) and month 6 (4.99 vs. 4.21, P = 0.008). No significant differences in medication adherence were seen among groups.  Regular nurse-administered asthma education with additional pharmacist counseling improves asthma knowledge and clinical symptoms in asthma patients.

title: Individualized asthma self-management improves medication adherence and markers of asthma control.
abstract: Adherence to inhaled anti-inflammatory therapy and self-management skills are essential parts of the asthma treatment plan to improve asthma control and prevent exacerbations. Whether self-management education improves long-term medication adherence is less clear.



A 24-week prospective, randomized controlled trial was performed to study the effect of self-management education on long-term adherence to inhaled corticosteroid (ICS) therapy and markers of asthma control.



After stabilization on ICS medication during a run-in phase, 95 adults with moderate-to-severe asthma were recruited from a large metropolitan community, and 84 were randomized to individualized self-management education, including self-monitoring of symptoms and peak flow or usual care with self-monitoring alone. The key components of the 30-minute intervention were asthma information, assessment, and correction of inhaler technique; an individualized action plan based on self-monitoring data; and environmental control strategies for relevant allergen and irritant exposures. The intervention was personalized based on pulmonary function, allergen skin test reactivity, and inhaler technique and reinforced at 2-week intervals.



Participants randomized to the self-management intervention maintained consistently higher ICS adherence levels and showed a 9-fold greater odds of more than 60% adherence to the prescribed dose compared with control subjects at the end of the intervention (P = .02) and maintained a 3-fold greater odds of higher than 60% adherence at the end of the study. Perceived control of asthma improved (P = .006), nighttime awakenings decreased (P = .03), and inhaled beta-agonist use decreased (P = .01) in intervention participants compared with control subjects.



Our results show that individualized asthma self-management education attenuates the usual decrease in medication adherence and improves clinical markers of asthma control.

title: A Randomized Controlled Behavioral Trial of a New Adult Asthma Self-management Program:
abstract: The purpose of the present research was to design and implement an adult asthma self-management program using a randomized control design. A total of 24 participants served in the control group while 21 participants served in the intervention group. Those in the intervention group participated in 7 weekly meetings which consisted of interactive discussions, problem-solving, social support and a behavior modification procedure. The behavior modification procedure consisted of homework assignments in which participants were asked to self-monitor and record asthma specific behaviors (including peak expiratory flow, avoidance/removal of asthma triggers, and controller medication adherence) and general lifestyle behaviors (including drinking water, practicing relaxation, washing hands and exercising).Results: A series of two factor mixed design analysis of variance computations indicated statistically significant interactions. When compared to participants in the control condition, those individu...

title: Personality in Adulthood: A Five-Factor Theory Perspective
abstract: Facts and Theories of Adult Development. A Trait Approach to Personality. Measuring Personality. The Search for Growth or Decline in Personality. Cross-Cultural Perspectives on Personality and Aging. The Course of Personality Development in the Individual.  Qualifications and Rival Hypotheses.  Ego Psychologies and Projective Methods. Adult Development as Seen through the Personal Interview. A Five-Factor Theory of Personality. The Influences of Personality on the Life Course.

title: The Influence of Personality Traits on Reported Adherence to Medication in Individuals with Chronic Disease: An Epidemiological Study in West Sweden
abstract: Limited research exists exploring the influence of personality on adherence behaviour. Since non-adherence is a major obstacle in treating prevalent chronic diseases the aim was to determine whether personality traits are related to reported adherence to medication in individuals with chronic disease.  Individuals with chronic disease (n = 749) were identified in a random population sample of 5000 inhabitants aged 30–70 in two municipalities in West Sweden. Data on five personality traits, Neuroticism, Extraversion, Openness to experiences, Agreeableness, and Conscientiousness, and medication adherence behaviour was collected by questionnaires. Statistical analyses resulted in a negative relationship between Neuroticism and medication adherence (P<0.001), while both Agreeableness (P<0.001) and Conscientiousness (P<0.001) were positively related to adherence. At high levels of Conscientiousness, low adherence was related to higher scores in Neuroticism. At high levels of Agreeableness, low adherence was related to low scores in Conscientiousness and high scores in Openness to experiences.  This study demonstrated that multiple personality traits are of significant importance for adherence behaviour in individuals with chronic disease. The findings suggest that several personality traits may interact in influencing adherence behaviour. Personality traits could putatively be used to focus efforts to educate and support patients with high risk of low medical adherence.

title: Personality, adherence, asthma control and health-related quality of life in young adult asthmatics.
abstract: Striving for improved adherence and asthma control is of vital concern in today's asthma management. Several influential factors have been identified, but the importance of personality traits has been insufficiently explored. The aim was first to determine whether personality traits in young adult asthmatics are related to asthma control and health-related quality of life (HRQL), and second to examine the influences of personality traits on adherence to regular asthma medication treatment.



Young adult asthmatics, 22 years of age (n=268) completed questionnaires. Statistical analyses were performed.



The personality traits Negative Affectivity and Impulsivity correlated negatively with asthma control, whereas in women Hedonic Capacity correlated positively with asthma control.  Alexithymia and asthma control predicted the mental dimension of HRQL. Asthma control and physical activity predicted the physical dimension of HRQL. Among respondents with regular asthma medication (n=109), Impulsivity correlated negatively with adherence. In men, Antagonism and Alexithymia were associated with low adherence. Additionally, Alexithymia, Hedonic Capacity and Negative Affectivity showed non-linear relationships with adherence, meaning that initially increased scores on these personality traits scales were associated with increased adherence but higher scores did not increase adherence. Respondents who were prescribed a single inhaler combining ICS and LABA reported higher adherence than those with monotherapies.



These data suggest that personality can influence how asthma patients adhere to asthma medication treatment, and report their control and HRQL. Tools determining personality traits may be useful in the future in individualizing management of asthma patients.

title: The influence of personality traits and beliefs about medicines on adherence to asthma treatment.
abstract: To explore the influence of personality traits and beliefs about medicines on adherence to treatment with asthma medication.



Respondents were 35 asthmatic adults prescribed controller medication. They answered questionnaires about medication adherence, personality traits, and beliefs about medicines.



In gender comparisons, the personality traits "Neuroticism" in men and "adherence to medication" were associated with lower adherent behaviour. Associations between personality traits and beliefs in the necessity of medication for controlling the illness were identified. Beliefs about the necessity of medication were positively associated with adherent behaviour in women. In the total sample, a positive "necessity-concern" differential predicted adherent behaviour.



The results imply that personality and beliefs about medicines may influence how well adults with asthma adhere to treatment with asthma medication.