Asthma Management Handbook

Providing information, skills and tools for asthma self-management for adults

Recommendations

Provide or arrange education in asthma self-management, including (all of):

  • self-monitoring of asthma control based on symptoms (and peak expiratory flow monitoring, if used)
  • inhaler technique
  • a written asthma action plan
  • the importance of regular medical review.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Gibson et al. 20021
  • Gibson et al. 20022
  • Gibson and Powell, 20043
  • National Asthma Council Australia, 20084
  • Powell and Gibson, 20025

Assess each patient's inhaler technique at every opportunity, even for patients who have been using the inhaler for many years.

  • Have the patient demonstrate their inhaler technique, while checking against a checklist of steps for the specific device.
  • Demonstrate correct technique using a placebo device and correct any specific errors identified.
  • Have the patient repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.
  • Provide the checklist as a reminder, and write down or highlight any steps that were done incorrectly (e.g. on a sticker attached to their inhaler or on a pictorial instruction sheet).

Note: Watch the person use their inhaler – don’t just ask if they think they know how to use it properly.

Checklists of steps, and videos demonstrating correct technique, for various types of inhalers are available on National Asthma Council Australia’s website.

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group

Key evidence considered:

  • Basheti et al. 20136
  • National Asthma Council Australia, 20187
  • The Inhaler Error Steering Committee, 20138
  • Basheti et al. 20089
  • Basheti et al. 201710
  • Bosnic-Anticevich et al. 201011
  • Capanoglu et al. 201512
  • Crane et al. 201413
  • Giraud et al. 201114
  • Lavorini 201415
  • Newman 201416
  • Hesso et al 201617

Last reviewed version 2.0

 

Advise patients to seek emergency medical care immediately if they experience any of these danger signs:

  • severe breathing problems
  • symptoms get worse very quickly
  • reliever has little or no effect
  • difficulty saying sentences
  • blue lips
  • drowsiness.

The person and their family should know that they must call an ambulance and give asthma first aid if they see any of these danger signs. 

How this recommendation was developed

Consensus

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

More information

Asthma self-management for adults

Effective self-management requires:

  • adherence to the agreed treatment regimen
  • correct use of inhaler devices for asthma medicines
  • monitoring asthma control (symptoms, with addition of peak expiratory flow for some patients)
  • having an up-to-date written asthma action plan and following it when asthma worsens
  • management of triggers or avoidance (if appropriate)
  • regular medical review.

Self-monitoring of asthma

Self-monitoring by the patient, based on symptoms and/or peak expiratory flow, is an important component of effective asthma self-management.1

For most patients, a daily diary is not necessary. Patients should be trained to take note if their symptoms worsen or their reliever use increases, so they can implement their written asthma action plan and/or get medical care as appropriate.

Internet-based self-management algorithms in which patients adjust their treatment monthly on the basis of control scores have been reported to be more effective than usual care.18 In patients with partly and uncontrolled asthma, weekly self-monitoring and monthly treatment adjustment may improve asthma control.19

Asthma self-management education

Patients need careful asthma education to enable them to manage their asthma effectively.

Education in asthma self-management that involves self-monitoring (by either peak expiratory flow or symptoms), regular medical review and a written action plan improves health outcomes for adults with asthma.1 Training programs that enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.1

Information alone does not appear to improve health outcomes in adults with asthma,  although perceived symptoms may improve.2

Structured group asthma education programs are available in some regions. Contact Asthma Australia in your state or territory for information about available asthma education programs.

Close
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.20

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
Written asthma action plans for adults

Every person with asthma should have their own written asthma action plan.

When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.3 Written asthma action plans are effective if based on symptoms5 or personal best peak expiratory flow (not on percentage predicted).3

How to develop and review a written asthma action plan

A written asthma action plan should include all the following:

  • a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • when peak flow falls below an agreed rate (for those monitoring peak flow each day)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name of the person writing the action plan, and the date it was issued.

Table. Options for adjusting medicines in a written asthma action plan for adults Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/42

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

Asset ID: 43

Close

Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans2122 is available online.

Close
Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,23, 24,2525, 26 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.23, 24, 27, 28, 29, 30

Poor asthma symptom control is often due to incorrect inhaler technique.31, 32

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

Last reviewed version 2.0

Close
Self-monitoring in adults using peak expiratory flow

Peak flow monitoring is no longer routinely used in Australia, but is recommended for patients with severe asthma, a history of frequent flare-ups, or poor perception of airflow limitation.

Peak expiratory flow can be monitored at home using a mechanical or electronic peak flow meter, either regularly every day or when symptoms are worse. For patients who are willing to measure peak flow regularly, morning and evening readings can be plotted on a graph or recorded in a diary.

When peak flow monitoring results are recorded on a graph, the same chart should be used consistently so that patterns can be recognised. Flare-ups are easier to detect when the chart or image has a low ratio of width to height (aspect ratio), i.e. is compressed horizontally.33

When a person’s written asthma action plan is based on peak expiratory flow, instructions should be based on personal best, rather than predicted values. Personal best can be determined as the highest reading over the previous 2 weeks. When a person begins high-dose inhaled corticosteroid treatment, personal best peak expiratory flow reaches a plateau within a few weeks with twice daily monitoring.34

Close
'Wheeze-detecting' devices

Some hand-held devices and smart phone applications are marketed for detecting and measuring wheeze by audio recording and analysis.

There is not enough evidence to recommend these devices and apps for use in monitoring asthma symptoms or asthma control in adults or children, or in distinguishing wheeze from other airway sounds in children.

  • Reliance on these devices could result in over- or under-treatment.

Last reviewed version 2.0

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.35 Mechanisms may include effects of stress on the immune system35 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.36 There is a complex interrelationship between:36

  • 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.37 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.36

Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.36 Poor health literacy has been associated with poor asthma control,38 poor knowledge of medications,39 and incorrect inhaler technique.39 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.36 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.36 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.36

Australian research suggests that there are probably many Australians with limited health literacy.40 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).36 However, even well-educated patients might have trouble with basic health literacy skills.36

Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.36 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.36 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.41 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.36

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. Gibson PG, Powell H, Wilson A, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD001117. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001117/full
  2. Gibson PG, Powell H, Wilson A, et al. Limited (information only) patient education programs for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 1: CD001005. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001005/full
  3. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004; 59: 94-99. Available from: http://thorax.bmj.com/content/59/2/94.full
  4. National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. National Asthma Council Australia, Melbourne, 2008. Available from: http://www.nationalasthma.org.au/publication/inhaler-technique-in-adults-with-asthma-or-copd
  5. Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD004107. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004107/full
  6. Basheti, I. A., Bosnic-Anticevich, S. Z., Armour, C. L., Reddel, H. K.. Checklists for dry powder inhaler technique: a review and recommendations. Respir Care. 2013; 59: 1140-1154. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24129338
  7. National Asthma Council Australia,. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. NACA, Melbourne, 2018. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  8. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  9. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  10. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  11. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010; 47: 251-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20394511
  12. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. J Asthma. 2015; 52: 838-45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26037396
  13. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ Prim Care Respir Med. 2014; 24: 14034. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188403
  14. Chorao, P., Pereira, A. M., Fonseca, J. A.. Inhaler devices in asthma and COPD – an assessment of inhaler technique and patient preferences. Respir Med. 2014; 108: 968-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24873873
  15. Lavorini, F.. Inhaled drug delivery in the hands of the patient. J Aerosol Med Pulm Drug Deliv. 2014; 27: 414-8.
  16. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert Opin Drug Deliv. 2014; 11: 365-78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24386924
  17. Hesso, I., Gebara, S. N., Kayyali, R.. Impact of community pharmacists in COPD management: Inhalation technique and medication adherence. Respir Med. 2016; 118: 22-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27578467
  18. van der Meer V, Bakker MJ, van den Hout WB, et al. Internet-based self-management plus education compared with usual care in asthma: a randomized trial. Ann Intern Med. 2009; 151: 110-20. Available from: http://annals.org/article.aspx?articleid=744598
  19. Wechsler, M. E., Laviolette, M., Rubin, A. S., et al. Bronchial thermoplasty: Long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol. 2013; 132: 1295-302. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23998657
  20. Castro, M, Rubin, A S, Laviolette, M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med. 2010; 181: 116-124. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19815809
  21. Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
  22. Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
  23. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  24. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
  25. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  26. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  27. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  28. Levy ML, Dekhuijzen PN, Barnes PJ, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med. 2016; 26: 16017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27098045
  29. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  30. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
  31. Harnett, C. M., Hunt, E. B., Bowen, B. R., et al. A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic. J Asthma. 2014; 51: 440-5.
  32. Hardwell, A., Barber, V., Hargadon, T., et al. Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Prim Care Respir J. 2011; 20: 92-6. Available from: http://www.nature.com/articles/pcrj201088
  33. Jansen J, McCaffery KJ, Hayen A, et al. Impact of graphic format on perception of change in biological data: implications for health monitoring in conditions such as asthma. Prim Care Respir J. 2012; 21: 94-100. Available from: http://www.nature.com/articles/pcrj20124
  34. Reddel HK, Marks GB, Jenkins CR. When can personal best peak flow be determined for asthma action plans?. Thorax. 2004; 59: 922-4. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1746886/
  35. 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/
  36. 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
  37. 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
  38. 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
  39. 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/
  40. 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
  41. 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