Pregnancy & Asthma

Asthma rates are increasing nationwide, and asthma is a particularly alarming problem in inner-city African-American communities. In fact, African Americans are at least twice as likely to be hospitalized and to die from asthma as white Americans.

Although there are good medications that can prevent and treat airway constriction, a hallmark of the disease, studies have found that many people do not take their asthma mediation regularly, but their reasons are not always clear. In a small study published in the May 2003 Journal of Allergy and Clinical Immunology, Dr. Andrea Apter, associate professor of medicine at the University of Pennsylvania, and Maureen George, MSN, RN, AE-C, coordinator of the Comprehensive Asthma Care Program at the University of Pennsylvania, asked low-income, urban African Americans with asthma why they did not regularly use their mediation.

The study authors found that there are many barriers to adherence, some of which can be addressed through improved doctor-patient communication. Below, Dr. Apter and George share their study findings as well as strategies for maintaining a drug schedule.

What were you hoping to learn from this study?
DR. ANDREA APTER: Understanding why patients don't take their medicines is a very complicated issue. As providers, we only see one aspect of the patient: when the patient comes to clinic. We don't know about all the things in their life that impact whether they take their medicines.

MAUREEN GEORGE: We have these great medications that people don't seem to have accepted. Before we design interventional studies to try and improve compliance, we wanted to conduct these focus groups to get a better understanding of the attitudinal beliefs that may influence patients' decision-making.

What were some of the reasons people weren't taking their medicine consistently?
MAUREEN GEORGE: Many of the patients skipped their medicines when they came home late because they believed it was safer to omit a dose than to take a dose late. And yet, if you were to ask any asthma provider, we would say it would be much wiser to take that dose than to skip a dose.

There were also some specific fears of the side effects of the medications that weren't true, such as the belief that the medication could cause organ damage, cancer and infertility or sterility.

One of the barriers that was specific to this population was the belief that the patient's assessment of their disease control was superior to that of their provider.

DR. ANDREA APTER: Insurance coverage was another barrier. Some patients get 28 days worth of medicine through their insurance because that's considered a months' worth. They can't get those extra two days refilled until the new month, so they run out. That causes patients to not take their medication one day so that they have it when they really need it.

What are the consequences of not maintaining an asthma regimen?
MAUREEN GEORGE: The risk of undertreating asthma is, at best, suboptimal control and, at worst, death. Suboptimal control could include more acute asthma attacks and the risk of developing permanent damage to the lungs. It could also include more acute care needs—such unplanned doctor visits or intensive care admissions—absenteeism from work or school, poor exercise tolerance, poor quality of life and nocturnal awakenings.

What strategies did patients find helpful?
MAUREEN GEORGE: Asthma educators and clinicians have been told by the experts that patients should just leave their medication at home and take it when they get up in the morning and go to bed at night. The patients in this study told us that they felt that the provider should encourage them to carry their medicines with them because they have chaotic lifestyles. Another theme was to offer fewer medicines that can be taken less frequently.

DR. ANDREA APTER: Different people had different solutions. For example, one woman thought of taking her medicine when her children took theirs. A man who went to work early in the morning put his medicine in the car and would take it on the way to work.

What did patients say about their relationship with their doctors?
DR. ANDREA APTER: Our patients liked their physicians, who came from one practice. But many of them described experiences in the past where they didn't feel that a physician listened to them. They felt the physician or the provider wasn't empathetic or didn't provide them the time and the individualized attention that they needed.

How can caregivers or family members help a patient stay on schedule?
DR. ANDREA APTER: If the patient's family has the time, coming with the patient to appointments is always helpful because they can support the patient. If that is not possible, a phone conversation with doctor, while the patient listens, could be helpful.

MAUREEN GEORGE: Some patients said, "My family members don't trust these medicines and don't trust the doctors." But many of the patients also felt that the family members were actually tougher on them. They didn't want their family members to know that they hadn't been taking their medicine. If family members came to the doctor with the patient, they'd have a better understanding of the burden of the disease and the complexity of the regimen. Family members might then learn to be more understanding of lapses in therapy and still provide some motivation for the patient to stay on the straight and narrow.