With an attack I associate it more with going into hospital: understandings of asthma and psychosocial stressors; are they related to use of services?

The comparison between pulmonary rehabilitation with music therapy and pulmonary rehabilitation alone on respiratory drive, cortisol level and asthma control in patients hospitalized with asthma exacerbation

INTRODUCTION

Much emphasis is being placed on the role of music therapy as an easy-to-use, noninvasive and relatively cheap method of asthma treatment. The objective of this interventional double-blinded randomized controlled trial was to assess whether music therapy, as a complementary modality to pulmonary rehabilitation, can help to improve respiratory drive, asthma control and quality of life in patients with asthma exacerbation.

METHODS

Hospitalized patients with asthma exacerbation enrolled in the study were randomly assigned to experimental (music therapy) or control (popular science program) group. Both groups during hospitalization received standard pharmacotherapy accompanied by respiratory physiotherapy. Respiratory drive, asthma control, quality of life and serum cortisol in all participants were assessed at the beginning and at the end of their hospitalizations.

RESULTS

The experimental group consisted of 39 asthmatics and 34 subjects with asthma were assigned to the control group. During the hospitalization, the levels of the inspiratory occlusion pressure for the first 0.1 s of inspiration (P0.1) decreased (p = 0.004) and the maximum P0.1 increased (p = 0.041) only in the experimental group. The serum cortisol level decreased in both groups (p = 0.001). The changes in asthma control and quality of life did not reach significant levels in either subject group.

CONCLUSION

Passive music therapy and its effects on the mental state of patients seem to improve the efficiency of the respiratory system. The results of this experimental study demonstrate that a complementary music therapy has beneficial effects on the treatment of asthma exacerbations in adults.

Patient Perceptions of Living with Severe Asthma: Challenges to Effective Management

BACKGROUND

The management of severe asthma poses many challenges related to treatment, adherence, and psychosocial morbidity. There is little direct data from the patient perspective to understand and negotiate the complexities of managing severe asthma.

OBJECTIVE

To explore the patient perceptions of living with severe asthma and the experience of managing severe asthma, in order to better understand the support that might promote more effective self-management for severe asthma.

METHODS

Participants were recruited from a specialist Difficult Asthma Service. Semistructured interviews were conducted by researchers independent of the patient's care. Interviews were transcribed verbatim and inductive thematic analysis was performed.

RESULTS

Twenty-nine participants (13 male: mean [standard deviation] age, 49.5 [13.6] years: mean Asthma Control Questionnaire 2.2 [1.2]) participated in an interview. Analysis resulted in 4 major themes describing the experience and challenges to managing severe asthma: understanding of severe asthma, emotional impact of living with severe asthma (subtheme: fear of hospitalization), public perceptions of asthma, and concerns about medications.

CONCLUSIONS

Health care professionals need to consider and discuss with patients their perceptions of severe asthma and the relevant treatments; particular attention should focus around education of disease control and actively exploring thoughts around hospitalization. Our data highlight the potential for psychological and social support to enhance self-management by directly addressing the wide-ranging individual challenges patients face. There is also a need for greater public awareness and education about severe asthma to minimize patient distress particularly in the work environment.

"This illness diminishes me. What it does is like theft": A qualitative meta-synthesis of people's experiences of living with asthma

BACKGROUND

What matters to people in their everyday experiences of living with asthma is influenced by a diverse range of personal, social, medical and environmental factors. Previous reviews of the asthma literature have largely focused on medical aspects of asthma or specific population groups with particular needs.

OBJECTIVE

To identify, describe and synthesize from the available qualitative literature the views and experiences of adults living with asthma.

METHOD

We systematically searched for qualitative studies reporting on the personal experience of living with asthma. A meta-synthesis approach was used to analyse and interpret the data. Key themes relating to personal perspectives on asthma were identified and grouped into overarching concepts.

RESULTS

We identified 26 studies. There was a paucity of literature on the physical burden of asthma symptoms and the role of social support. Our synthesis generated a central concept of the "work" associated with living with asthma: work was of a personal nature, and at times an intensely emotional experience. Individuals tailored their behaviour in response to demands of the physical and social environment, including interactions with health-care professionals.

CONCLUSION

This is the first systematic review of the qualitative literature reporting on people's own perspectives of living with asthma. Our findings draw attention to the nuances and sensitivities surrounding patient experiences of self-management. Medical care is a central plank of managing chronic conditions, but our health-care systems are now expected to deliver patient-centred care. Considering the broader aspects of asthma management, beyond that of symptoms and treatment, will help to facilitate comprehensive care.

Psychosocial working conditions as determinants of asthma self-management at work: A systematic review

OBJECTIVE

Asthma exerts a considerable impact on patients and their employers. While adequate self-management is able to improve patients' prognosis, its actual implementation in everyday life may depend on contextual factors. We aimed to review the literature on the potential determinants of asthma self-management at the workplace.

DATA SOURCES

We systematically searched Medline and PsycINFO using terms related to the key concepts of interest (i.e., adult asthma, working conditions, and self-management).

STUDY SELECTION

We included original studies published in peer-reviewed journals in English or German since 1992 addressing any type of asthma self-management behavior as the outcome and any type of working condition as the determinant.

RESULTS

Upon implementation of a multi-stage selection process, seven articles were included. As those studies showed considerable methodological heterogeneity, a qualitative analysis was applied. A first study identified three different adaptation profiles among employees with asthma with implications for self-management behavior. Another study suggested that concerns about taking time off from work may be associated with the utilization of emergency ambulance services for asthma. Five studies among workers with various chronic illnesses addressed determinants of self-disclosure, coping with acute symptoms (e.g., medication use at work), and the potential effect of practical and emotional support from line managers or colleagues on self-management.

CONCLUSION

Our review indicates that the evidence for a potential link of occupational factors with asthma self-management at work is relatively sparse. Future research should take a more comprehensive approach by considering multiple types of working conditions and asthma self-management behaviors simultaneously.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Multidisciplinary treatment in children with problematic severe asthma: A prospective evaluation

OBJECTIVE

For children with problematic severe asthma, achieving adequate control of asthma is difficult. The aim of this prospective observational study was to evaluate the effects of intensive multidisciplinary inpatient treatment on multiple outcome variables in children with problematic severe asthma.

METHODS

Participants were 89 children with problematic severe asthma (mean age 13.6 ± 2.5 years) treated in tertiary care clinics at high altitude (Switzerland) or sea level (Netherlands) and their parents (85 mothers, 55 fathers). The primary outcome variable was the Childhood Asthma Control Test (C-ACT). Other outcome variables were forced expiratory volume in 1 sec (FEV₁ ), fractional concentration of exhaled nitric oxide (FeNO), quality of life [PAQLQ(S)], children's coping (UCL-A), parents' report of behavioral problems (CBCL), and parenting stress (PSI/NOSI). Evaluations were taken pre-treatment, post-treatment, and 3-6 months follow-up. Median [P25;P75] treatment duration 74 [56;80] days; Median follow-up interval 131 [103;177] days.

RESULTS

The percentages of children showing controlled asthma (C-ACT) were 18% (pre-treatment), 69% (post-treatment), and 44% (follow-up). The vast majority of the children (80%) showed an improvement on C-ACT with 4% showing a deterioration. On C-ACT, FeNO, quality of life, and behavioral problems, improvements at post-treatment were highly significant. Improvements generally remained at a functional level at follow-up. Children's coping and parenting stress in parents did not change.

CONCLUSIONS

The improvement in asthma control and other outcome variables suggests that multidisciplinary inpatient treatment is an effective approach for a heterogeneous group of children with asthma that remained uncontrolled in secondary care. Pediatr Pulmonol. 2017;52:588-597. © 2016 Wiley Periodicals, Inc.

Patient-physician communication about work-related asthma: what we do and do not know

BACKGROUND

Effective patient-physician communication is the key component of the patient-physician relationship.

OBJECTIVE

To assess the proportion of ever-employed adults with current asthma who talked about asthma associated with work with their physician or other health professional and to identify factors associated with this communication.

METHODS

The 2006 to 2010 Behavioral Risk Factor Surveillance System Asthma Call-Back Survey data from 40 states and the District of Columbia for ever-employed adults (≥18 years old) with current asthma (N = 50,433) were examined. Multivariable logistic regression analyses were conducted to identify factors associated with communication with a health professional about asthma and work.

RESULTS

Among ever-employed adults with current asthma, 9.1% were ever told by a physician that their asthma was related to any job they ever had and 11.7% ever told a physician or other health professional that this was the case. When responses to the 2 questions were combined, the proportion of those who communicated with a health professional about asthma and work was 14.7%. Communication with a health professional about asthma and work was associated with age, race or ethnicity, employment, education, income, insurance, and urgent treatment for worsening asthma.

CONCLUSION

A small proportion of patients with asthma might communicate with a health professional about asthma associated with work. Future studies should examine whether patients with asthma ever discussed with a health professional the possibility that their asthma might be related to work to provide information on the frequency of patient-clinician communication about asthma related to work.

Operationalising unscheduled care policy: a qualitative study of healthcare professionals' perspectives

BACKGROUND

UK health policy aims to reduce the use of unscheduled care, by increasing proactive and preventative management of patients with long-term conditions in primary care.

AIM

The study explored healthcare professionals' understanding of why patients with long-term conditions use unscheduled care, and the healthcare professionals' understanding of their role in relation to reducing the use of unscheduled care.

DESIGN AND SETTING

Qualitative study interviewing different types of healthcare professionals providing primary care or unscheduled care services in northwest England.

METHOD

Semi-structured interviews were conducted with 29 healthcare professionals (six GPs; five out-of-hours GPs; four emergency department doctors; two practice nurses; three specialist nurses; two district nurses; seven active case managers). Data were analysed using framework analysis.

RESULTS

Healthcare professionals viewed the use of unscheduled care as a necessary component of care for patients with long-term conditions. Those whose roles involved working to targets to reduce the use of unscheduled care described a tension between this and delivering optimum patient care. Three approaches to reducing unscheduled care were described: optimising the system; negotiating the system; and optimising the patient.

CONCLUSION

Current policy to reduce the use of unscheduled care does not take account of the perceptions of the healthcare professionals who are expected to implement them. Lipsky's theory of street-level bureaucrats provides a framework to understand how healthcare professionals respond to imposed policies. Healthcare professionals did not see the use of unscheduled care as a problem and there was limited commitment to the policy targets. Therefore, policy should aim for whole-system change rather than reliance on individual healthcare professionals to make changes in their practice.

Asthma from the patient's perspective

BACKGROUND

Asthma is a chronic disease with considerable burden on health and economy. Despite growing knowledge about causes and treatment, many patients have uncontrolled asthma, activity and social limitations and reduced quality of life (QOL). Coping with asthma could be developed in a social and scientific context and influenced by personal experience.

OBJECTIVE

To investigate the asthmatic's perspective on asthma and how coping mechanisms with this disease were influenced by health professionals and networks.

METHODS

Asthma and QOL questionnaires were sent to 1191 individuals, who had participated in a population-based clinical study in 2004. Of the 7271 responders (72.7%), 10 chronic asthmatics (4 males and 6 females) with different asthma severity grades were recruited to in-depth interviews. The results were interpreted according to selected theories, especially Antonovsky's salutogenic theory on how comprehensibility, manageability and meaningfulness contribute to sense of coherence and successful coping with stressor/disease.

RESULTS AND CONCLUSION

Asthma comprehensibility was limited by both the lack of structured information about asthma diagnosis, treatment and prognosis and insufficient follow-up. The informants experimented with what worked and developed individual ways to accomplish satisfactory management. They adjusted their own medication and sometimes stopped prophylactic medicine as they did not detect an immediate effect. Many informants put their asthma into perspective, comparing it to what could have been worse. The unnoticeable development of asthma had probably triggered a gradual adaptation making it more complex for asthmatics to estimate severity. This together with their relative view of asthma might have led to gradual and uncritical accept of bothersome symptoms and reduced the need to seek professional advice or make important changes, e.g. eliminating exposure to irritating agents at work. Avoidance was a recurrent phenomenon as the asthmatics tended to drop physical activities with others instead of improving treatment. Several stated that they did not like to flash their asthma. They had concerns about being labelled as 'inadequate'. Physicians are urged to consider these tendencies and underlying the some of the mechanisms of 'living with asthma' in order to achieve proper asthma treatment and insure their patients' wellbeing.

Why do patients with long-term conditions use unscheduled care? A qualitative literature review

Unscheduled care (UC) refers to non-routine face-to-face care, such as accident and emergency care, out-of-hours care, or walk-in centres. Current health service policy aims to reduce its use. Unscheduled care is common in people with long-term conditions such as diabetes, asthma, chronic obstructive pulmonary disease and coronary heart disease. By reviewing qualitative research literature, we aimed to understand the breadth of psychosocial and other influences on UC use in people with long-term conditions. Few qualitative papers specifically address UC in patients in these disease groups. Therefore, our literature search also included qualitative research that explored factors potentially relevant to UC use, including attitudes to healthcare use in general. By searching Medline, Embase, Psycinfo and Cinahl from inception to 2011, we identified 42 papers, published since 1984, describing relevant original research and took a meta-ethnographic approach in reviewing them. The review was conducted between Spring 2009 and April 2011, with a further search in December 2011. Most papers reported on asthma (n = 13) or on multiple or unspecified conditions (n = 12). The most common methods reported were interviews (n = 33) and focus groups (n = 13), and analyses were generally descriptive. Theoretical and ethical background was rarely explicit, but the implicit starting point was generally the 'problem' of UC, and health-care, use in general, decontextualised from the lives of the patients using it. Patients' use of UC emerged as understandable, rational responses to pressing clinical need in situations in which patients thought it the only option. This belief reflected the value that they had learned to attach to UC versus routine care through previous experiences. For socially or economically marginalised patients, UC offered access to clinical or social care that was otherwise unavailable to them.

The prospective association between behavioural problems and asthma outcome in young asthma patients

AIM

The aim of this prospective study was to examine the association between behavioural problems and medical and psychological outcomes in clinically treated children and adolescents with asthma.

METHODS

Patients (n = 134) were recruited from two high-altitude asthma clinics in Switzerland and one asthma clinic in the Netherlands. Outcome measures were Asthma Control Test (ACT), Paediatric Asthma Quality of Life Questionnaire (PAQLQ(S)), forced expiratory volume in 1 sec (FEV1 ) and fractional concentration of exhaled nitric oxide (FeNO). Parents completed the Child Behaviour Checklist (CBCL) (predictor variable). Data were collected at the start and end of treatment. Multiple regression analysis was used while adjusting for demographic variables, clinic and length of stay.

RESULTS

More severe internalizing behavioural problems were associated with less improvement of total quality of life (t = -2.26, p = 0.03) and the domains symptoms (t = -2.04, p = 0.04) and emotions (t = -2.3, p = 0.02) after clinical treatment. Behavioural problems were not associated with a change of lung function measurements (FEV1 and FeNO) and asthma control (ACT) during treatment.

CONCLUSION

A focus of healthcare professionals on the treatment of internalizing behavioural problems may optimize the quality of life in clinically treated youth with asthma.

Effectiveness of a comprehensive lifestyle modification program for asthma patients: a randomized controlled pilot trial

OBJECTIVE

The aim of the study was to investigate the effectiveness and feasibility of conducting a complementary 8-week comprehensive lifestyle modification program (CLMP) compared to standard care in patients with bronchial asthma over a 6-month period.

METHODS

This was a randomized controlled pilot trial with two groups: intervention (N = 15) group and attention-placebo control (N = 14) group. The intervention group received an 8-week CLMP in addition to standard care. Quality of life, asthma control, lung function, reduction of rescue medication, perceived stress, and psychosocial and spiritual status were measured at the end of the intervention and at the 4-month follow-up.

RESULTS

In the intervention group, there was a statistically significant difference in the improvements of quality of life, asthma control, lung function, and the reduction of rescue medication intake at both the end of the intervention and at the 4-month follow-up, with no change being observed in the control group. Significant stress reduction and greater psychosocial and spiritual well-being were observed during the 8-week CLMP in the intervention group. At the end of the intervention, the measures of stress and psychological and spiritual well-being reached statistical significance.

CONCLUSIONS

Preliminary findings suggest that adding a CLMP to standard care in patients with bronchial asthma offers greater clinical benefit than standard care alone and also suggest that conducting a large randomized clinical trial is feasible.

Puerto Rican families' experiences of asthma and use of the emergency department for asthma care

Puerto Ricans have been found to have higher asthma prevalence rates than non-Hispanic whites, blacks, and all other Hispanic subgroups. They also have the highest rates of emergency department (ED) use for the management of their asthma. Using a hermeneutic phenomenological approach, the aim of this study was to describe the lived experience of Puerto Rican families caring for their child's asthma and using the ED for asthma care. Six themes were generated from in-depth interviews with 10 Puerto-Rican caregivers: (1) The Folklore of Asthma, (2) Culture and the Medicine Woman, (3) In Awe of Asthma, (4) Praying to God, (5) The Decision-Time to Go, and (6) The ED Environment. The findings emphasize the necessity of establishing and maintaining a therapeutic partnership between primary care providers and families of children with asthma. The results may be used as a foundation for understanding motivations for seeking asthma care in the ED.

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.

Family support and asthma outcomes in adolescents: barriers to adherence as a mediator

PURPOSE

Asthma morbidity in children is associated with family psychosocial functioning. Although the family plays a pivotal role in maintaining optimal asthma care, the mechanism of how family support influences asthma outcomes is not well understood. The purpose of this study was to examine the role of barriers to adherence in mediating the effect of family support on asthma outcomes in adolescents.

METHODS

The sample included 126 adolescents with asthma aged 13-20 years, living in the Northeast United States. The sample consisted of 49% Whites and 51% minorities, including primarily Blacks (38%) followed by Hispanic (11%). Adolescents provided self-reported data. Structural equation modeling was performed to examine the direct and indirect relationships between family support and asthma outcomes.

RESULTS

Family support was positively associated with asthma control and quality of life. These significant associations were mediated by barriers to adherence. Particularly, family support was found to reduce barriers concerning adolescents' negative attitudes toward medication and healthcare providers, which in turn improved asthma control and quality of life symptoms, emotional functioning, and activity domains. Adolescents' cognitive difficulty also tended to mediate the relationship between family support and emotional functioning.

CONCLUSION

This study highlights the beneficial effects of family support in improving asthma outcomes in adolescents. Family support exerts the positive effect by ameliorating barriers to treatment adherence in adolescents, particularly the barriers associated with negative attitudes and cognitive challenges. The findings underscore the importance of incorporating family assessment and intervention in caring for adolescents with asthma.

Illness perceptions: impact on self-management and control in asthma

PURPOSE OF REVIEW

Outcome in asthma is determined not only by pulmonary function or other biomedical characteristics. An important determinant of asthma outcome is illness perceptions: patients' subjective beliefs and emotional responses to their illness. Illness perceptions influence patients' coping and self-management behavior, and thereby outcome.

RECENT FINDINGS

We review recent studies on associations between illness perceptions and outcome in patients with asthma, with a range of respondents and caregivers, with varying degree of asthma severity, and in different settings of medical care. Most studies pertain to substantial numbers of patients, and have been performed in different countries, adding to the external validity of the findings. All studies report substantial effects of illness perceptions on various categories of outcome: illness perceptions reflecting personal control over the illness are associated with a positive outcome, that is, asthma control. Findings point at the importance and clinical relevance of addressing patients' illness perceptions, and suggest that this may improve outcome in asthma care. Well conducted intervention studies on this topic are called for in order to improve outcomes and quality of life in asthma patients.

SUMMARY

Illness perceptions influence the way in which patients with asthma cope and their self-management of the illness. Illness perceptions can be assessed quite easily and directly, they inform healthcare providers about the psychosocial responses of patients towards their asthma, they are responsive to change in the clinical encounter or via self-management intervention training. Exploring patient's illness perceptions, therefore, is a crucial component of good clinical care.

Barriers to asthma self-management in adolescents: Relationships to psychosocial factors

Asthma morbidity in adolescents often results from inadequate asthma self-management. This study was to explore barriers to self-management perceived by adolescents and to examine the associations between barriers and psychosocial factors including knowledge, attitude and self-efficacy. This cross-sectional study included a total of 126 adolescents with asthma (13-20 years) representing diverse race/ethnicity groups with a wide range of socioeconomic status. Self-reported data were analyzed using descriptive statistics, factor analysis and hierarchical regression. The most frequently endorsed barrier (63%) was adolescents' unwillingness to give up "the things the doctors say I have to give up," followed by difficulty in remembering to take care of their asthma (53%), and then "trying to forget" that they have asthma (50%). Psychosocial factors accounted for 32% of the variance in total barrier perceptions. Factor analysis revealed barriers in four domains including negativity toward providers and the medication regimen, cognitive difficulty, peer/family influence and denial. Self-efficacy was found to be the most influential factor that showed strong negative associations with all four barrier subscales independent of the levels of asthma control and sociodemographic characteristics. Poor attitudes toward asthma were also associated with barriers of cognitive difficulty and social influence after adjusting for other factors. Males consistently reported higher total barriers and barriers of negativity, social influence and denial. The gender differences were not explained by psychosocial and sociodemographic factors. This study suggests that psychosocial factors are strong predictors of barriers to self-management in adolescents. Particularly, promoting self-efficacy may be beneficial in addressing the barriers. Special attention is needed to address the higher propensity for barriers in males.