Adolescents, asthma and adherence

Teenagers are notoriously bad with their asthma management.

ADOLESCENTS with asthma remain a highly vulnerable group due to the impact of living with a chronic illness during a time of rapid physical, psychological and cognitive change.

Adherence to an asthma management plan – in particular, regular use of a preventer – is often very difficult for teens. A recent article in the Journal of Allergy and Clinical Immunology outlines the reasons why this occurs.¹

The authors investigated adherence to preventive asthma therapy and explored beliefs and attitudes to asthma in older urban adolescents and their suggestions to improve adherence.

Among the 40 adolescents (50% female, 75% African American, mostly low income, aged 15-17 years) all had moderate or severe persistent asthma and were on fluticasone/salmeterol (F/S).

FEV₁ was greater than 90% for all but six adolescents; 43% had attended an emergency department; 20% required hospital admission in the last year; while four had cough and wheeze at the time of the interview.

Two semi-structured interviews one month apart were analysed for themes using the Health Beliefs Model. F/S use was monitored electronically for the month and adherence was calculated.

Electronic monitoring data was available for 37 of the 40 adolescents with a median adherence of 43% (range 25-62 per cent). Adherence was better in younger compared with older teenagers, and surprisingly there was no significant difference by sex, race, income, FEV₁ at enrolment, emergency department visits or hospitalisation.

Self-reporting was highly correlated with electronic monitoring. Neither self-reported nor electronic adherence was associated with a perception of asthma interfering with activities. Nor were they associated with the belief that inhaled corticosteroids were beneficial or with recording of missed doses.

Other findings included:

• 38 out of 40 reported that they did not take F/S as prescribed
• 29 reported asthma interfered with their daily activities.

However, there were few perceived benefits of taking F/S:

• six said not helpful
• six said not necessary
• eight had no improvement with regular treatment
• seven were ambivalent
• eight were asymptomatic so they believed they did not need it
• 18 did not like the taste
• three had fears of addiction to their medication.

The greatest perceived barriers were difficulties organising their time and setting priorities so that they “just forget” (55%), others complained they had “too many meds” (33%), while losing their inhaler, staying over at friends’ houses and negotiating split family households were also highlighted as problems adversely affecting adherence.

The participants did however suggest strategies to promote adherence to treatment, with 73% suggesting organisational change such as keeping their inhaler near their toothbrush, using reminder notes, receiving rewards and reluctantly admitting that parent reminders, while annoying, were helpful.

Unfortunately, this group of adolescents were pessimistic about their ability to change, saying they were “not confident” they could overcome forgetting their inhaler.

A pattern emerged of improved adherence when unwell and decreased adherence when symptoms were intermittent, illustrating that the concept of preventive medication was not meaningful to this age group. The combination of significant barriers and low perceived benefit resulted in the poor adherence to inhaled corticosteroids.

This research illustrates the importance of clinicians looking at beliefs around illness and medication, as these have an enormous impact on adherence, not just for asthma but in all chronic illnesses.

One-on-one communication – to clarify concerns, examine and address health beliefs, and discuss the proposed treatment plan, expectations and possible side-effects – is a first step to engaging adolescents and improving self-management.

Associate Professor Susan Towns, MBBS, FRACP, MMH, is head of adolescent medicine at the Children’s Hospital at Westmead, NSW.

Reference

Naimi DR, et al. Adolescents and asthma: Why bother with our meds? J Allergy Clin Immunol 2009; 123:1335-41.