Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma


  • Funding and conflict of interest: Dr Foster has received a research grant from GlaxoSmithKline and AstraZeneca and lecture fees from GlaxoSmithKline, Pharmaceutical Society of Australia and AstraZeneca. Dr Smith has received a research grant from Novo Nordisk and lecture fees from Pharmaceutical Society of Australia. Prof Sawyer has participated in an advisory board for Astra Zeneca. Prof. Rand has participated in advisory boards for TEVA and received consultancy fees for TEVA and Merck. A/Prof. Reddel has participated in advisory boards for AstraZeneca and Novartis, received consultancy fees from GlaxoSmithKline, lecture fees from AstraZeneca, Getz Pharma and MSD, research grants from AstraZeneca and is participating in a data monitoring committee for AstraZeneca, GlaxoSmithKline Merck and Novartis. Dr Bosnic-Anticevich and Prof. Usherwood have no potential conflicts of interest with respect to this article. Funding for this study was provided by Asthma Foundation NSW. Support for J. M. F.'s salary was provided in the form of an unrestricted research grant from AstraZeneca Australia. Medication was provided by GlaxoSmithKline. The Asthma Control Test was used with permission of GlaxoSmithKline and in accordance with conditions specified by GlaxoSmithKline under the terms of its license with the copyright holder, QualityMetric Incorporated. Smartinhalers were purchased from Nexus6, Auckland, New Zealand. None of the above bodies had any role in the design, conduct, analysis or interpretation of the study, and they did not see the manuscript prior to submission. The authors alone are responsible for the content and writing of the paper.


Background:  Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence-related beliefs or behaviours for individual patients.

Aims:  To identify potentially modifiable beliefs and behaviours that predict electronically recorded adherence with controller therapy.

Methods:  Patients aged ≥14 years with doctor-diagnosed asthma who were prescribed inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) completed questionnaires on medication beliefs/behaviours, side-effects, Morisky adherence behaviour score and Asthma Control Test (ACT), and recorded spirometry. Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of adherence were identified by univariate and multivariate analyses.

Results:  99/100 patients completed the study (57 female; forced expiratory volume in 1 s mean ± standard deviation 83 ± 23% predicted; ACT 19.9 ± 3.8). Mean electronically recorded adherence (n= 85) was 75% ± 25, and mean self-reported adherence was 85% ± 26%. Factor analysis of questionnaire items significantly associated with poor adherence identified seven themes: perceived necessity, safety concerns, acceptance of asthma chronicity/medication effectiveness, advice from friends/family, motivation/routine, ease of use and satisfaction with asthma management. Morisky score was moderately associated with actual adherence (r=−0.45, P < 0.0001). In regression analysis, 10 items independently predicted adherence (adjusted R2= 0.67; P < 0.001). Opinions of friends/family about the patient's medication use were strongly associated with poor adherence. Global concerns about ICS/LABA therapy were more predictive of poor adherence than were specific side-effects; the one-third of patients who reported experiencing side-effects from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P= 0.015).

Conclusions:  This study identified several specific beliefs and behaviours which clinicians could use for initiating patient-centred conversations about medication adherence in asthma.