Asthma Management Handbook

Assessing patients’ adherence to asthma treatment

Recommendations

Do not assume the person is taking the dose prescribed most recently. Ask which asthma medicines the person is using, in a non-judgmental, empathic manner.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

Asset ID: 38

Close
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

If the person is not using prescribed preventer, use non-judgemental questions to find out why.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider whether any common barriers to correct use of medicines apply:

  • misunderstanding purpose of medicines
  • concerns about side effects
  • taking wrong dose
  • skipping doses to save on treatment costs
  • incorrect inhaler technique
  • poor perception of airflow limitation
  • social pressure from peer group, employer, colleagues or family (e.g. expectation that should have grown out of asthma)
  • beliefs about health that conflict with or undermine confidence in conventional asthma medicines.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Before considering any increase in dose or addition to treatment regimen (step up), check the patient’s adherence to the medication most recently prescribed.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Adherence to preventer treatment: adults and adolescents

Most patients do not take their preventer medication as often as prescribed, particularly when symptoms improve, or are mild or infrequent. Whenever asthma control is poor despite apparently adequate treatment, poor adherence, as well as poor inhaler technique, are probable reasons to consider.

Poor adherence may be intentional and/or unintentional. Intentional poor adherence may be due to the person’s belief that the medicine is not necessary, or to perceived or actual adverse effects. Unintentional poor adherence may be due to forgetting or cost barriers.

Common barriers to the correct use of preventers include:

  • being unable to afford the cost of medicines or consultations to adjust the regimen
  • concerns about side effects
  • interference of the regimen with the person’s lifestyle
  • forgetting to take medicines
  • lack of understanding of the reason for taking the medicines
  • inability to use the inhaler device correctly due to physical or cognitive factors
  • health beliefs that are in conflict with the belief that the prescribed medicines are effective, necessary or safe (e.g. a belief that the prescribed preventer dose is ‘too strong’ or only for flare-ups, a belief that asthma can be overcome by psychological effort, a belief that complementary and alternative therapies are more effective or appropriate than prescribed medicines, mistrust of the health professional).

Adherence to preventers is significantly improved when patients are given the opportunity to negotiate the treatment regimen based on their goals and preferences.1

Assessment of adherence requires an open, non-judgemental approach.

Accredited pharmacists who undertake Home Medicines Reviews can assess adherence while conducting a review.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

Asset ID: 38

Close
Close
Home Medicines Review and MedsCheck

Home Medicines Review

A Home Medicines Review involves the patient, their GP, an accredited pharmacist and a community pharmacy. Referral (Medicare Item 900) may be either direct to an accredited pharmacist, or to a community pharmacy that uses the services of an accredited pharmacist.

The accredited pharmacist visits the patient at their home, reviews their medicine regimen and provides a report to the person’s GP and usual community pharmacy. The GP and patient then agree on a medication management plan.

The aims of Home Medicines Review include detecting and overcoming any problems with the person’s medicines regimen, and improving the patient’s knowledge and understanding of their medicines.

Patients could be eligible for a Home Medicines Review if they (any of):

  • take more than 12 doses of medicine per day
  • have difficulty managing their own medicines because of literacy or language difficulties, or impaired eyesight
  • visit multiple specialists
  • have been discharged from hospital in the previous four weeks
  • have changed their medicines regimen during the past 3 months
  • have experienced a change in their medical condition or abilities
  • are not showing improvement in their condition despite treatment
  • have problems managing their delivery device
  • have problems taking medicines because of confusion, limited dexterity or poor eyesight.

MedsCheck

MedsCheck involves review of a patient’s medicines by a registered pharmacist within the pharmacy.

Patients are eligible if they take multiple medicines, and they do not need a referral from a GP.

The pharmacist makes a list of all the person’s medicines and medication or monitoring devices, and discusses them with the patient to identify any problems. If necessary, the pharmacist refers any issues back to the person’s GP or other health professional.

Close
Psychosocial factors affecting asthma self-management

Psychosocial factors can affect asthma symptoms and outcomes in children and adults. These can include biological, individual, family and community-level factors, which can have synergistic effects in an individual with asthma.2 Mechanisms may include effects of stress on the immune system2 and effects of life circumstances on patients’ and families’ ability to manage asthma.

Relationships between psychosocial and cultural factors

Important influences on asthma outcomes include the person’s asthma knowledge and beliefs, confidence in ability to self-manage, perceived barriers to healthcare, socioeconomic status, and healthcare system navigation skills, and by the quality of interaction and communication between patient and healthcare provider.3 There is a complex interrelationship between:3

  • patient factors (e.g. health literacy, health beliefs, ethnicity, educational level, social support, cultural beliefs, comorbidities, mental health)
  • healthcare provider factors (e.g. communication skills, teaching abilities, available time, educational resources and skills in working with people from different backgrounds)
  • healthcare system factors (e.g. the complexity of the system, the healthcare delivery model, the degree to which the system is oriented towards chronic disease management or acute care, and the degree to which the system is sensitive to sociocultural needs).

Health literacy

‘Health literacy’ refers to the individual’s capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions.4 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.3

Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.3 Poor health literacy has been associated with poor asthma control,5 poor knowledge of medications,6 and incorrect inhaler technique.6 Aspects of health literacy that have been associated with poorer asthma outcomes in adults include reading skills, listening skills, numeracy skills, and combinations of these.3 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.3 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.3

Australian research suggests that there are probably many Australians with limited health literacy.7 It may be possible to identify some groups of patients more likely to have inadequate health literacy, such as people living in regions with low socioeconomic status, and those with low English literacy (e.g. people with limited education, members of some ethnic minorities, immigrants, and the elderly).3 However, even well-educated patients might have trouble with basic health literacy skills.3

Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.3 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.3 Accordingly, all self-management skills need to be explained carefully, simply and repeatedly, and all written material should be clear and easy to read. Special consideration is needed for patients from culturally and linguistically diverse communities, including Aboriginal and Torres Strait Islander people.

Psychosocial support and improving health literacy

Psychosocial interventions that include asthma education may improve health-related quality of life for children and adolescents with asthma and their families.8 However, simply providing education might not improve a person’s health literacy, since it also depends on other factors like socioeconomic status, social support, and is influence by the provider and the healthcare system.3

Asthma Australia provides personal support and information for people with asthma and parents of children with asthma through the Asthma Australia Information line by telephone on 1800 Asthma (1800 278 462) or online.

Close

References

  1. Wilson SR, Strub P, Buist SA, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010; 181: 566-77. Available from: http://ajrccm.atsjournals.org/content/181/6/566.full
  2. Yonas MA, Lange NE, Celedon JC. Psychosocial stress and asthma morbidity. Curr Opin Allergy Clin Immunol. 2012; 12: 202-10. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320729/
  3. Rosas-Salazar C, Apter AJ, Canino G, Celedon JC. Health literacy and asthma. J Allergy Clin Immunol. 2012; 129: 935-42. Available from: http://www.jacionline.org/article/S0091-6749(12)00128-5/fulltext
  4. Ratzan S, Parker R. Introduction. In: Selden C, Zorn M, Ratzan S, Parker R, editors. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, USA, 2000; v-vi. Available from: http://www.nlm.nih.gov/archive//20061214/pubs/cbm/hliteracy.html
  5. Adams RJ, Appleton SL, Hill CL, et al. Inadequate health literacy is associated with increased asthma morbidity in a population sample. J Allergy Clin Immunol. 2009; 124: 601-603. Available from: http://www.jacionline.org/article/S0091-6749(09)00859-8/fulltext
  6. Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005; 172: 980-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718412/
  7. Adams RJ, Appleton SL, Hill CL, et al. Risks associated with low functional health literacy in an Australian population. Med J Aust. 2009; 191: 530-4. Available from: https://www.mja.com.au/journal/2009/191/10/risks-associated-low-functional-health-literacy-australian-population
  8. Clarke SA, Calam R. The effectiveness of psychosocial interventions designed to improve health-related quality of life (HRQOL) amongst asthmatic children and their families: a systematic review. Qual Life Res. 2012; 21: 747-64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21901377