Similarities and differences between asthma health care professional and patient views regarding medication adherence

Psychometric assessment of the Adherence to Asthma Medication Questionnaire in asthma patients in China: a validation study

BACKGROUND

Patients' medication adherence plays a critical role in the treatment and rehabilitation of disease. However, few tools are currently available that can be used to identify the reasons for their nonadherence with their medication regimens. It is possible to evaluate both the level of medication adherence of a patient as well as the reasons for it using the Adherence to Asthma Medication Questionnaire (AAMQ). The purpose of this study was to adapt the AAMQ for use in Chinese patients and a variety of asthma patients.

METHODS

A total of 242 asthma patients were recruited from Jinzhou in China. The Adherence to Asthma Medication Questionnaire was translated and back-translated using the Brislin translation model. Test-retest reliability, internal consistency, and stability all play a large role in determining the reliability of a scale. Confirmatory factor analysis was used to examine the scale's construct validity, and expert consultation was used to verify the scale's content validity. Statistics were deemed significant at p < 0.05.

RESULTS

The Cronbach's α value of the Chinese version of the AAMQ was 0.866, and the coefficient values for the three domains ranged between 0.702 and 0.798. The split-half reliability and stability values were 0.794 and 0.772, respectively. The content validity index of the scale (S-CVI) was 0.923, and the content validity index of the level of scale entry was 0.857-1.000. According to the confirmatory factor analysis, the chi-square degreed of freedom were 1.484, and the model fitting indices were all within normal limits.

CONCLUSIONS

The AAMQ had good reliability and validity for asthmatic patients. The results of the scale's assessment can be used as a criterion for medication adherence among asthmatic patients and to understand the causes. This study provides a reference for solving the problem of medication adherence among asthma patients and implementing targeted nursing measures.

PATIENT OR PUBLIC CONTRIBUTION

Gratitude is extended to all individuals collaborating in completing the survey and to the author.

The Design of a Persuasive Game to Motivate People with Asthma in Adherence to Their Maintenance Medication

Objective

This study aimed to design a persuasive game, using objective adherence data, to motivate people with asthma to adhere to their medication regimen.

Methods

A participatory user-centered design approach was employed, involving end-users and other stakeholders throughout the study. The approach consisted of four phases. Semi-structured interviews and a survey were conducted to understand user needs and reasons for poor adherence (Phase 1: define). Key themes were identified, leading to the formulation of behavior change strategies and design and game requirements. Several design directions were ideated, resulting in a concept for a serious game (Phase 2: ideate). Two rounds of user-tests were performed to evaluate a prototype of the serious game in terms of usability, perceived impact on medication adherence and motivation (Phase 3: prototype and Phase 4: evaluate).

Results

Findings from semi-structured interviews (n = 6) and the online survey (n = 20) revealed that people's non-adherence was often attributed to the perception of asthma as an episodic condition, the delayed experienced effect of maintenance inhalers, and lack of knowledge regarding difference of effect between maintenance and reliever inhalers. The study used behavior change strategies to translate these insights into design requirements for the development of the narrative-based persuasive game Ademgenoot. This six-week challenge-based game combines various behavior change strategies, including personal goal setting and continuous visual feedback, as well as persuasive game design elements, such as a narrative and rewards, with the aim of enhancing motivation to adhere to their medication regimen. User-testing (n = 8; round 1 and 2) showed that Ademgenoot is feasible in clinical practice and has the potential to support people with mild asthma in adherence to their maintenance medication.

Discussion

Future efforts should be directed towards a larger evaluation to assess the impact on motivation and inhaler use behaviour.

Medication Adherence in People with Asthma: A Qualitative Systematic Review of Patient and Health Professional Perspectives

Background

Increased medication adherence leads to better asthma control and health outcomes. However, many studies have found that patient adherence to maintenance medication is poor.

Aim

We undertook a meta-synthesis of qualitative studies, to investigate asthma patient and healthcare professionals' perspectives of medication adherence.

Methods

This systematic review was reported by following the PRISMA guidelines. The Joanna Briggs Institute (JBI) meta-aggregative approach was used for the qualitative synthesis. The protocol was registered in PROSPERO (CRD42022346831).

Results

In total, 12 articles were included in the review. These articles reported findings from 433 participants in total, which included 315 patients and 118 healthcare professionals. Four synthesised findings with sub-themes were identified from the reviewed studies. These synthesised findings were described as: 1) The role of relationship and communication with/between Healthcare Professionals in medication adherence; 2) Insufficient information from Healthcare Professionals acting as a barrier for adherence; 3) How patient's attitude/beliefs effect their adherence to medication; and 4) Patients' personal behaviour and other relevant barriers.

Conclusion

The synthesized findings provide a strong evidence-base of patient and health professionals' perspectives and behaviours toward medication adherence, which helps to identify and address non-adherence. Healthcare providers can use these findings to support patients' adherence to asthma medications. The findings suggest that empowering people to make informed decisions around medication adherence rather than "adherence controlling" by health professionals is very important. Effective dialogue and appropriate education are critical approaches to increase medication adherence.

A patient decision aid for mild asthma: Navigating a new asthma treatment paradigm

INTRODUCTION

In mild asthma, as-needed budesonide-formoterol offers similar protection from severe exacerbations as daily inhaled corticosteroids (ICS), with lower ICS exposure but slightly increased symptoms. We sought to develop an electronic decision aid to guide discussions about the pros and cons of these first-line options, while identifying and integrating user preferences.

METHODS

Following International Patient Decision Aid Standards, we created a mild asthma decision aid prototype comparing convenience, clinical outcomes, cumulative ICS dose exposure, costs, and side-effects of each option. After face validation, the prototype was iteratively adapted through rapid-cycle development. Each cycle consisted of a patient focus group and a primary care physician interview. We made user preference-based improvements after each round, until reaching a pre-set stopping criterion (no new critical issues identified). We then performed a summative qualitative content analysis.

RESULTS

Over 5 cycles, we recruited 21 asthma patients (12/21 women, 10/21 ≥ 60 years old) and 5 physicians. Serial changes included simplification and reduction of text and reading level, inclusion of an ICS "myths" section and elaboration of patient-friendly infographics for numerical comparisons. User preferences fell within Content, Format, and tool use Process themes. In response to decision-making preferences, we created a complementary one-page conversation aid for patient-provider use at the point-of-care.

CONCLUSIONS

We present preference-based electronic patient decision and conversation aids for treatment of mild asthma. Our user preference analyses offer useful insights for development of such tools in other chronic diseases. These tools now require integration into point-of-care workflows for measurement of real-world uptake and impact.

An audit of the British Thoracic Society asthma discharge care bundle in a teaching hospital

BACKGROUND

The UK asthma mortality rate has risen by 33% over a decade. The national enquiry into 195 asthma-related deaths revealed that most of these deaths were preventable. The Asthma Discharge Care Bundle (ADCB) is recommended for use when discharging patients with an acute asthma attack and/or exacerbation.

AIM

To review the implementation of the British Thoracic Society (BTS) bundle in a teaching hospital.

METHODS

A 12-month retrospective audit was conducted on 86 adult patients treated for asthma attacks.

FINDINGS

The results of the audit indicated that the hospital has complied with the ADCB. In total, 85% of patients had their inhaler technique checked, but 62% of them were not provided with any written inhaler use instructions. The respiratory clinical nurse specialists were more compliant with most of the bundle statements than the medical team.

CONCLUSION

The findings highlighted the need for asthma education sessions for all health professionals with emphasis on record-keeping skills.

Physician's perspective regarding asthma guided self-management: directives or guidance?

INTRODUCTION

Asthma guided self-management enhances patients' control of their condition under the guidance of the treating physician. The aim of the present study was to understand how physicians perceive, endorse, uptake, and support asthma guided self-management.

METHODS

We conducted a secondary supplementary analysis of data originally collected as part of a multicenter collective case study in which physicians treating patients with asthma were interviewed. Using reflective thematic analysis, we aimed to explore physicians' understanding of guided asthma self-management as related to four ideas, namely: (a) understanding of the disease management and treatment goals; (b) defining medical frame and guidance; (c) describing the importance of patient-physician relationship; and (d) implementing asthma guided self-management.

RESULTS

Evidence indicates that physicians perceived optimal guided self-management as related to patients' adherence to physician's instructions and recommendations, supported by the adjustment of prescribed pharmaceutical therapy contingent upon patient's symptoms. Some physicians also perceived behavior change and environmental control along with the medical recommendations. While physicians' perception of asthma and its treatment were aligned with the recommended guidelines-i.e., patient-centered care approach based on guided self-management, the actual guidance offered to patients remained primarily directive and paternalistic. Non-pharmacological approaches, such as exercise, smoking cessation, patient self-monitoring, and self-management supported by education and written self-management plans, were given little consideration in the context of the recommended treatment plan.

A Scoping Review of International Barriers to Asthma Medication Adherence Mapped to the Theoretical Domains Framework

BACKGROUND

Internationally, adult asthma medication adherence rates are low. Studies characterizing variations in barriers by country are lacking.

OBJECTIVE

To conduct a scoping review to characterize international variations in barriers to asthma medication adherence among adults.

METHODS

MEDLINE, EMBASE, Web of Science (WOS), and CINAHL were searched from inception to February 2017. English-language studies employing qualitative methods (eg, focus groups, interviews) were selected to assess adult patient- and/or caregiver-reported barriers to asthma medication adherence. Two investigators independently identified, extracted data, and collected study characteristics, methodologic approach, and barriers. Barriers were mapped using the Theoretical Domains Framework and findings categorized according to participants' country of residence, countries' gross national income, and the presence of universal health care (World Health Organization definitions).

RESULTS

Among 2942 unique abstracts, we reviewed 809 full texts. Among these, we identified 47 studies, conducted in 12 countries, meeting eligibility. Studies included a total of 2614 subjects, predominately female (67%), with the mean age of 19.1 to 70 years. Most commonly reported barriers were beliefs about consequences (eg, medications not needed for asthma control, N = 29, 61.7%) and knowledge (eg, not knowing when to take medication, N = 27, 57.4%); least common was goals (eg, asthma not a priority, N = 1, 2.1%). In 27 studies conducted in countries classified as high income (HIC) with universal health care (UHC), the most reported barrier was participants' beliefs about consequences (N = 17, 63.3%). However, environmental context and resources (N = 12, 66.7%) were more common in HIC without UHC.

CONCLUSION

International adherence barriers are diverse and may vary with a country's sociopolitical context. Future adherence interventions should account for trends.

Understanding Patient Perspectives on Medication Adherence in Asthma: A Targeted Review of Qualitative Studies

Adherence to asthma medications is generally poor and undermines clinical outcomes. Poor adherence is characterized by underuse of inhaled corticosteroids (ICS), often accompanied by over-reliance on short-acting β₂-agonists for symptom relief. To identify drivers of poor medication adherence, a targeted literature search was performed in MEDLINE and EMBASE for articles presenting qualitative data evaluating medication adherence in asthma patients (≥12 years old), published from January 1, 2012 to February 26, 2018. A thematic analysis of 21 relevant articles revealed several key themes driving poor medication adherence, including asthma-specific drivers and more general drivers common to chronic diseases. Due to the episodic nature of asthma, many patients felt that their daily life was not substantially impacted; consequently, many harbored doubts about the accuracy of their diagnosis or were in denial about the impact of the disease and, in turn, the need for long-term treatment. This was further compounded by poor patient-physician communication, which contributed to suboptimal knowledge about asthma medications, including lack of understanding of the distinction between maintenance and reliever inhalers, suboptimal inhaler technique, and concerns about ICS side effects. Other drivers of poor medication adherence included the high cost of asthma medication, general forgetfulness, and embarrassment over inhaler use in public. Overall, patients' perceived lack of need for asthma medications and medication concerns, in part due to suboptimal knowledge and poor patient-physician communication, emerged as key drivers of poor medication adherence. Optimal asthma care and management should therefore target these barriers through effective patient- and physician-centered strategies.

The role of pharmacists in the pharmaceutical care of asthma patients in Yogyakarta, Indonesia: the patients' views

Introduction: Community pharmacists are one of the most frequently accessed health professionals who can be involved in the provision of ongoing asthma management within the primary care setting. The aim of this study was to identify patients' views regarding current asthma care provided by their pharmacists and their perspectives on future pharmacy-based asthma services.Methods: This is a qualitative approach with an interview guide. Asthma patients were purposively selected. Interviews were conducted from April to June 2017. Patient's opinions about asthma and its management and their experiences regarding asthma care provided by pharmacists were collected. Data were analyzed using content analysis.Results: Thirty-three interviews were conducted. Asthma literacy was low. There was dis-engagement with the health care system, with only a few participants trusting conventional health care professionals. Alternative medicine systems and practitioners were better trusted and participants had strong preferences for family/peer involvement in their asthma care. Participants also had misunderstandings regarding their asthma disease and medications. Participants had experienced little pharmaceutical care provided by pharmacists but would welcome it in the future.Conclusion: Given the accessibility of community pharmacy venues and readiness of the profession for more involved care of chronic disease patients, it may be recommended that Indonesian community pharmacists should adopt the provision of pharmaceutical care models for asthma. Such pharmaceutical care models need to incorporate patients' unique sociocultural health beliefs, preferences for alternative medicines and family/social peer involvement as well as stronger collaboration between pharmacists and physicians.

Understanding patients' perceptions of asthma control: a qualitative study

Asthma control is suboptimal for many sufferers despite the existence of effective treatments. Patients' self-management is influenced by their perceptions of asthma and its treatment. This study explored sufferers' perceptions of asthma control and their influence on self-management behaviours.Participants (n=42) recruited from primary and secondary care asthma clinics in London in the UK each underwent a qualitative interview exploring perceptions and experiences of asthma control. Purposive sampling ensured variation in disease severity, degree of asthma control, age and socioeconomic status. Grounded theory was employed in thematic analysis of transcribed interviews.Five themes relating to perceptions of asthma control and self-management were identified: personal meaning of control, intermittent prevention, compromising control to avoid medication, pharmacological agents overemphasised in control and the role of asthma review in control. Within the first theme, some participants had an internal barometer of the level of symptoms that indicated their asthma was getting "out of control" that was set much higher than Asthma Control Test criteria.The findings provide new insights into patients' perceptions of asthma control. Symptoms indicative of poor control were often tolerated as part of living with asthma. Identification of barriers and drivers to self-management highlight potential targets for strategies aimed at optimising asthma management.

Improving adherence to asthma medications: current knowledge and future perspectives

PURPOSE OF REVIEW

Poor adherence to asthma controller medications, particularly inhaled corticosteroids, has been well known for decades and is a major cause of uncontrolled asthma and increased healthcare utilization. This review presents recent evidence on factors leading to nonadherence in specific age groups, parents of young children, adolescents and young adults, adults, and the elderly. Novel management strategies including electronic sensors with associated smart phone applications for adherence improvement are discussed.

RECENT FINDINGS

Interventions to promote adherence must include a focus on issues important to the patient. Parents are concerned about adverse effects and the difficulty of medication administration in their child; adolescents and young adults need help with organizational skills and social barriers; adults may be more receptive to the need for daily medication after an acute exacerbation and acceptance of their disease; the elderly may have medication misuse issues associated with cognitive decline and other comorbidities related to aging. In all age groups, a trusting relationship with the provider is the key. New digital devices to track adherence may provide feedback to the patient and provider to evaluate and to promote adherence.

SUMMARY

Personalized approaches are required to address adherence barriers in target populations. Research on specific needs and barriers in target populations and development of appropriate strategies for use of new digital technology for adherence monitoring is needed.

Validation of the Polish version of Satisfaction with Asthma Treatment Questionnaire (SATQ)

INTRODUCTION

Among the chronically ill there is a tendency for non-compliance with medical recommendations, which is often due to low satisfaction with the offered treatment. Satisfaction with Asthma Treatment Questionnaire (SATQ) is a questionnaire for measuring satisfaction with the inhalation treatment of asthma in patients of more than 18 years of age. SATQ is a standardized tool that has not been previously used in Poland. SATQ consists of 4 domains: efficiency, ease of use, the burdening with asthma treatment and side effects and concerns.

AIM

To validate the Polish language version of SATQ questionnaire and an overall verification of the usefulness of the tool relative to trials from clinical practice.

MATERIAL AND METHODS

The degree of difficulty and comprehension of the questions and the reliability and validity of the Polish version of the questionnaire was determined in 67 patients with asthma (mean age: 45.8 ±14.3 years (range maximum - at least 18-65 years). The vast majority of patients in the study group have used the inhalers for more than 1 year and were educated in the field of aerosols management. The resulting scores are calculated by adding up the scores for each question and dividing by the number of questions. The reliability of the questionnaire design was verified using the Spearman rank correlation coefficients between elements and ranges between band assessments and evaluations and overall assessment of quality and patient satisfaction with treatment. Internal consistency and reliability of the tool was assessed using Cronbach's α. The values of Cronbach's α were evaluated with respect to the threshold value of 0.70.

RESULTS

SATQ questionnaire was understandable and easy to fill out for all subjects. The filling time of SATQ was designed as to be within 5-10 min. Cronbach's α was reached on all scales, demonstrating the reliability of the analyzed scale and lack of redundancy.

CONCLUSIONS

The Polish version of SATQ questionnaire meets the basic psychometric criteria and can be used to assess satisfaction with the inhalation treatment of asthma.

How can adherence to asthma medication be enhanced? Triangulation of key asthma stakeholders' perspectives

BACKGROUND AND OBJECTIVES

Adherence to daily asthma controller medication has been shown to be the most effective component of asthma self-management; however, patient's adherence to asthma medication remains poor. This study aimed to understand how patients' long-term asthma controller medication adherence may be improved and facilitated by comparing key asthma stakeholders' perspectives.

METHOD

Six focus group interviews including 38 asthma stakeholders (n = 13 patients, n = 13 pulmonologist physicians, and n = 12 allied healthcare professionals) were conducted. Interviews were qualitatively analysed.

RESULTS

Although similar themes were brought up across different asthma stakeholders, the way in which they were framed differed across stakeholders. The most salient discussion revolved around the content and the moment in which asthma education should be approached to facilitate patients' adherence to asthma medication.

CONCLUSION

Asthma medication adherence is a complex process and successful interventions aimed at its improvement would benefit from: (a) making an effort to understand patients' experiences and negotiate the treatment regimen, rather than imposing recommendations; (b) considering treatment as a shared responsibility involving the patient, the healthcare professional(s), and the patients' social networks; and,

Patients' perspective of barriers and facilitators to taking long-term controller medication for asthma: a novel taxonomy

Background

Although asthma morbidity can be prevented through long-term controller medication, most patients with persistent asthma do not take their daily inhaled corticosteroid. The objective of this study was to gather patients’ insights into barriers and facilitators to taking long-term daily inhaled corticosteroids as basis for future knowledge translation interventions.

Methods

We conducted a collective qualitative case study. We interviewed 24 adults, adolescents, or parents of children, with asthma who had received a prescription of long-term inhaled corticosteroids in the previous year. The one-hour face-to-face interviews revolved around patients’ perceptions of asthma, use of asthma medications, current self-management, prior changes in self-management, as well as patient-physician relationship. We sought barriers and facilitators to optimal asthma management. Interviews were transcribed verbatim and transcripts were analyzed using a thematic approach.

Results

Patients were aged 2–76 years old and 58% were female. Nine patients were followed by an asthma specialist (pulmonologist or allergist), 13 patients by family doctors or pediatricians, and two patients had no regular follow-up. Barriers and facilitators to long-term daily inhaled corticosteroids were classified into the following loci of responsibility and its corresponding domains: (1) patient (cognition; motivation, attitudes and preferences; practical implementation; and parental support); (2) patient-physician interaction (communication and patient-physician relationship); and (3) health care system (resources and services). Patients recognized that several barriers and facilitators fell within their own responsibility. They also underlined the crucial impact (positive or negative) on their adherence of the quality of patient-physician interaction and health care system accessibility.

Conclusions

We identified a close relationship between reported barriers and facilitators to adherence to long-term daily controller medication for asthma within three loci of responsibility. As such, patients’ adherence must be approached as a multi-level phenomenon; moreover, interventions targeting the patient, the patient-physician interaction, and the health care system are recommended. The present study offers a potential taxonomy of barriers and facilitators to adherence to long-term daily inhaled corticosteroids therapy that, once validated, may be used for planning a knowledge translation intervention and may be applicable to other chronic conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0044-9) contains supplementary material, which is available to authorized users.