Patient Education and Counseling 32 (1997) S43–S49

How do patients’ views about medication affect their

self-management in asthma?

L.M. Osman*
Respiratory Medicine Unit, Aberdeen Royal Hospitals Trust, Aberdeen AB25 2 ZN, Scotland, UK

Abstract

Successful management of asthma increasingly depends on decisions by patients about when and how to use
inhalers and tablets prescribed for their asthma control. Patients with negative attitudes to asthma medication may
not be willing to follow their management plan’s advice to increase medication when their symptoms worsen.
Patients do not always believe their doctors’ reassurance about side effects. Although patient dislike of steroid
medication is sometimes believed to be the main influence on reluctance to take medication, studies suggest that
patients dislike taking any medication regularly. Evidence shows that patients are no more likely to use a combined
inhaler regularly than separate steroid and relief inhalers. A proportion of patients with difficult to control asthma
follow a chaotic self-management style. Attitudes among these patients may reflect personal styles, and be difficult
to change. Among the majority of patients studies now show that patient self-management, and outcomes for
patients can be improved by structured behavioural interventions. For most patients attitudes to medication will
follow control of symptoms. The experience of successful control by medication, in the ways that patients think are
important, are most likely to influence patients in positive attitudes to medication. u 1997 Elsevier Science
Ireland Ltd.

Keywords: Patients; Asthma; Attitudes; Compliance

1. Introduction which has been discussed and decided by the

Successful management of asthma increasingly
depends on decisions by patients about when and
how to use inhalers and tablets prescribed for
their asthma control. It is now agreed that
patients should be given a management plan,
*Address for correspondence: Aberdeen Royal Infirmary,
Aberdeen, Scotland AB25 2ZN. Tel.: 1 44 1224 681818 ext
51223; fax: 1 44 1224 840 766; e-mail: l.osman@abdn.ac.uk
person with asthma and their doctor or nurse.
Although patients who have been given manage-
ment plans have better outcomes [1] patients
with negative attitudes to asthma medication
may not be willing to follow their management
plan’s advice to increase medication when their
symptoms worsen. Many studies [2–7] in general
practice and outpatient clinics show that patients
are reluctant to use asthma medication as rec-
ommended.

0738-3991 / 97 / $17.00 u 1997 Elsevier Science Ireland Ltd. All rights reserved.
PII S0738-3991( 97 )00095-5
S44 L.M. Osman / Patient Education and Counseling 32 (1997) S43 –S49
It is important to understand what shapes
patient attitudes to asthma medication, and how
far attitudes influence self-management in asth-
ma. Significant issues include:
1. Positive and negative feelings about medica-
tion: the patient’s dilemma
2. Why don’t patients believe what their doctors
tell them about medication?
3. Delivery method and type of medication: do
these influence attitudes?
4. Attitudes and personal styles of medication
management: chaos or control?
5. Can doctors change patient attitudes? Must
attitudes change before behaviour changes?
2. Positive and negative feelings about
medication: the patient dilemma
In 1991 Virji and Britten [8] surveyed 280
patients attending one general practice. They
found two themes in patient attitudes to illness
management. One cluster of attitudes favoured
self-care without prescription drug treatment.
The other cluster of attitudes favoured drug
treatment. Both sets of attitudes could be present
in the same person. Povar et al. [9] presented
four hypothetical clinical situations to 2000 mem-
bers of a Health Maintenance Organisation.
They found that 72% of patients said they would
prefer a non-prescription drug ‘‘home remedy’’
to treat symptoms presented in the scenarios. In
Australia Donnelly et al. [10] surveyed parents of
128 young children with asthma. She found that
although the majority agreed with the statement
‘‘the advantages of medication outweigh the
disadvantages for my child’’, and 96% of parents
said they always gave their child all the medica-
tion prescribed, 86% also said that medication
should not be used for long periods. As well,
46% said asthma medication is unnatural and
harmful to children, 31% said children’s bodies
are too small to cope with medication and 60%
said they sometimes forgot to give their child his
or her medication. Haire-Joshu [11] found that
adult emergency room attenders preferred inter-
mittent relief treatment using over the counter
medicines to long term preventive treatment. In
a study we carried out in Scotland [12] we found
many patients disliked taking any medication on
a regular daily basis and attitudes to asthma
medications did not necessarily become more
favourable as asthma severity increased.
This reluctance to use asthma medication
raises concern that people with asthma will not
follow the standard management plan recom-
mendation to double their puffs of inhaled ster-
oid when symptoms worsen. Sibbald [13] found
that many patients say that they delay taking
action as asthma symptoms worsen. Van der
Palen et al. [14] found that among 10 patients
only four followed doubling instructions, and
that even among this group all returned to
normal usage within a day or two of PEF
improvement, rather than continuing with the
higher dose for two weeks as recommended.
Interviews with the patients in this study showed
that they were reluctant to fully increase inhaled
steroid. They felt that it would be enough just to
take ‘‘a little more’’ rather than to double their
dose.
Conversely, although patients are often reluc-
tant to increase medication, they are likely to
decrease medication when symptoms vary. Pretet
et al. [15] found that among 450 French asthma
patients 82% tended to reduce their medication
when their asthma improved. Jobanputra and
Ford [4] in a survey of 52 general practice
patients who had had asthma attacks found that
38% had discontinued some aspect of asthma
therapy in the three months before the attack.
However, Lahdensuo et al.’s study [1] of 115
Finnish asthma patients found that patients did
comply with management plan instructions when
their asthma control worsened. In this study most
patients doubled their inhaled steroid as symp-
tom severity increased. Patients with a manage-
ment plan had significantly better symptom out-
comes, as well as quality of life improvement.
Lahdensuo et al.’s study was large, well con-
trolled, and allowed patients good opportunity to
discuss queries and concerns about their medica-
tions. It is the clearest evidence to data that
patients will vary medication according to a
written management plan, if this is accompanied
 L.M. Osman / Patient Education and Counseling 32 (1997) S43 –S49
by good information and education, within a
stable doctor patient relationship.
As well, studies in general practice show that
although patients have negative feelings about
medication they also want intervention from
their doctors, and want medication to control
symptoms. Martin et al. [16] found that patients
viewed prescribing as an important component of
satisfactory medical consultation. Gibson et al.
[17] found that adult patients with asthma pre-
ferred not to be solely responsible for deciding
how to manage their asthma, and tended to say
that they wanted direction from their doctors. In
diabetes, Ruggiero et al. [18] found, among 2000
patients, that patients were more likely to follow
their prescribed medication regimens than to
make changes in their lifestyle recommended by
their doctors.
These studies show that most people have
conflicting attitudes to medication. People are
generally reluctant to use medication continuous-
ly, but at the same time, want to control symp-
toms. Patient dislike of medication is not always
connected with patient concerns about known
side effects of their medications, but can be a
general reluctance to take any medication con-
tinuously. This means that dislike of medication
will not necessarily be altered by reassurance
about lack of side effects. Clinicians should start
from the view that patients do not naturally want
to take asthma medication if this can be avoided,
even if they accept that it is safe and helpful to
their symptoms.
3. Patients’ beliefs about what their doctors tell
them about medication
Ziebland [19] surveyed women seeking ‘‘day
after’’ hormonal contraception. Although most
were well informed about time limits and effec-
tiveness of treatment, and although they knew
that professional opinion regarded hormonal
contraception as safe, 43% believed it to be more
risky to their health than regular use of oral
contraception. Ziebland concluded that the
professional opinion on the safety of hormonal
emergency contraception was not fully accepted
S45
by lay clients. Murray [20] found that patients in
the ages 35 to 45 years were particularly likely to
try alternative and complementary treatment for
medical conditions. In the Pretet study [15]
mentioned above 48% of 450 asthma patients
had used over-the-counter medication to control
asthma, in preference to prescription medication
Patients do not always see doctors and other
health professionals as disinterested information
providers. Patients use a range of lay and semi-
professional advice sources to confirm or test
information from doctors. A study by Manfredi
[21] of 257 patients with cancer found that most
patients sought supplementary information.
Many used an independent charity (the National
Institute Cancer Information Service). Patients
with good relationships with their doctors were
likely to bring this information back to the
medical consultation for discussion. Forty two
percent of these patients discussed the infor-
mation they had obtained with their doctor. In
the UK the National Asthma Campaign runs a
telephone helpline for asthma patients and their
families, and health professionals. The help line
has more that 300 calls each week. Frequent
topics include drug devices and self-management
of medication.
Other doctors and other health professionals
may give patients conflicting advice about their
medications. Lantner [22] found that 48% of
surveyed pharmacists in Chicago advised patients
with asthma to avoid anti-histamines because
they believed these worsened asthma symptoms.
Most people consult with friends and family
about how to manage symptoms in illness and
chronic conditions. This is normal, and shared
knowledge can be useful. For instance, a study
[23] of use of a paediatric emergency department
rated appropriateness of visit for almost 500
parents. Parents who had consulted non-medical
advice before coming to the emergency depart-
ment were found to make more appropriate
visits than parents who had not had advice.
However, this does mean that people with asth-
ma are continually confronted, through the
media, family and friends, with suggestions for
non drug management of asthma (hypnotherapy,
acupuncture, herbal remedies, new breathing
S46 L.M. Osman / Patient Education and Counseling 32 (1997) S43 –S49
techniques). This conflicting advice can be con-
fusing. Slack [24] found in discussions with teena-
gers that they reported that they did not disobey
their doctor’s advice, but they had inconsistent
advice from parents, teachers and school nurses.
Patients are most likely to be satisfied with
prescribing decisions if they feel they have been
involved in them. However, Makoul [25] found,
in a study of 271 consultations in Oxford, that
doctors overestimated the extent to which they
discussed patients’ ability to follow treatment
plans and elated patients’ opinions about the
prescribed medication. Patients were passive,
rarely offering their opinion or initiating any
discussion about aspects of the treatment.
Dowell [26] found, in discussion with patients
about treatment change, that patients were likely
to be dissatisfied with the communication they
received about the change. Cockburn [27] that
one factor contributing to compliance with an
antibiotic regimen was amount of advice pro-
vided by the doctor about the regimen.
Thus, patients may not believe what their
doctors tell them because in fact their doctors
have not told them very much. The standard
medical consultation of 5 or at the most 10 min
allows little time to discuss patient questions.
4. Delivery method and type of medication
In asthma more than almost any other type of
treatment, there is an enormous range of meth-
ods of delivering medication. These include
inhalers, tablets, syrups for children, devices for
delivering nebulised medication through masks
and even injections. The best-known delivery
method is the traditional metered dose inhaler or
puffer. This type of inhaler although standard in
general practice care of asthma, is difficult for
many patients to use effectively. Decker [28]
asked 150 patients in a Netherlands general
practice what they did when they felt an asthma
attack coming on. Twenty six percent said they
took no medication (a common response in
similar studies). Of the remaining 114 only 49
took appropriate medication, but most of these
were not able to demonstrate proper use of their
inhaler. Ineffective use of inhaler is likely to lead
to the patient believing that the medication itself
does not help. There is fairly good evidence that
patients prefer dry powder and breath activated
inhaled to traditional metered dose inhalers and
can use them more effectively [29,30] but we do
not know if this does actually result in greater
adherence to management plans. However, it
seems sensible to offer patients as much choice
as possible in inhaler device. Hand and Bradley
[31] carried out interviews with 40 patients with
asthma. Perceived benefits of inhalers and a
positive attitude to their inhalers were strongly
related to patient reported use of relief and
prevention inhalers. Satisfaction with their doc-
tor, and ease of obtaining inhalers was a stronger
influence on preventive medication use than on
relief inhaler use.
4.1. Patient preferences on tablets and inhalers
Tettersell [32] found that about one third of
100 general practice patients expressed a prefer-
ence for tablets rather than inhalers. Kelloway
[33] found that patients were more compliant
with theophylline (tablet) medication than with
inhaled anti-inflammatory medication. It may be
the case that some patients will be more com-
pliant with a regular tablet medication regimen.
However, new inhaler types are more acceptable
to patients in ease of use, and are more socially
acceptable than old style metered dose inhalers.
When tablet medication fills the same manage-
ment role as inhaled medication (with the new
generation of asthma medication and inhaler
types) we will be able to discover whether
patients are more willing to comply with tablet
medication.
4.2. Combining inhaled steroids and
bronchodilators
As many of the studies previously described
have shown, there do not appear to be strong
differences between patients’ attitudes to relief
(bronchodilator) medications and inhaled or tab-
let steroids. Bosley et al. [34] compared com-
pliance between patients using terbutaline (re-
 L.M. Osman / Patient Education and Counseling 32 (1997) S43 –S49
lief) and budesonide (steroid) in two separate
inhalers, and patients using one inhaler which
combined both medications. There was no differ-
ence in compliance with the separate relief and
steroid inhalers or the combined inhaler. This
study suggests that combined inhalers are unlike-
ly to overcome patient resistance to regular
medication use.
5. Personal styles of medication management
and attitudes to medication
Some people don’t follow medication regimens
simply because they are not good at following
any regular routine. Some people like to test
whether they ‘‘still need’’ their inhaled steroid by
stopping and starting their medication [35].
Other people prefer a very regular routine,
which they will not vary. Different use of asthma
medication may reflect basic differences in per-
sonal styles of management of symptoms. A
stated dislike of medication can provide a ‘‘ra-
tional’’ justification for intermittent use of medi-
cation, or use of non prescription medicine. In a
qualitative study of general attitudes to medica-
tion, Schafheutle [36] found that patients justified
using over the counter medication, rather than
prescription medication, on the grounds of con-
venience. The disadvantage of OTC medication
was judged to be that it was more expensive than
prescription medication. Thus, for this group,
factors other than efficacy of medication were
influencing patient decisions.
Patient reluctance to use medication has been
found to be connected with depression [37] and
psychological distress [38]. On the other hand,
patients with high anxieties about medication are
very often also high users of inhaled relief
medication. A proportion of patients with dif-
ficult to control asthma follow a chaotic self-
management style [39]. They are high users of
oral steroids and relief medication, but low users
of preventive steroid inhalers. In discussion, they
will express dislike of steroids, and fears of
becoming dependent on relief inhalers or ster-
oids, but they find it difficult to control their
chaotic response to symptoms.
S47
6. Changing attitudes to improve self-
management?
Studies now show that patient self-manage-
ment, and outcomes for patients can be im-
proved. It seems that the key factor in improve-
ment is that patients are given clear advice
specific to their prescribed medication [1,40]. As
well the evidence suggest that patients do better
when allowed opportunities to discuss their man-
agement with their doctors and nurses [41,42],
and are given information which explains and
supports a management plan [43,44]. But none of
these studies set out to change patient self-man-
agement by changing attitudes as the primary
determinant of self-care.
We might need to be quite cautious about
believing that patient self-care will improve by
giving information intended to change attitudes.
As pointed out above, patients may dislike
regular use of any medication; no matter how
much reassurance they are given about it. As
well, we know that just increasing knowledge
about asthma or medications does not in itself
have much benefit for patients. Does this mean
that attitudes can never be changed, and that
information about medication is unlikely to help
patients?
Probably we need to think about what kind of
attitudes, at what point in the ‘‘patient career’’.
For instance, information about medication is
important at initial diagnosis. At this point pa-
tients will be unsure of what is likely to happen.
They will have varying levels of knowledge
derived from friends and media, and varying
degrees of anxiety. Good discussion is likely to
encourage positive attitudes. Other critical times
for changing attitudes and styles of self-care are
likely to be at a first hospital admission for
asthma. Madge et al have recently shown that a
structured management intervention for parents
of hospitalised children is highly effective in
reducing re-admissions [45]. Any change of
medication is also likely to be a crucial time in
patient attitudes. Patients will be both hopeful
and apprehensive when medication is altered.
They will want to know just how this medication
differs from their former medication.
S48 L.M. Osman / Patient Education and Counseling 32 (1997) S43 –S49
What is likely to be the key to changing
attitudes to medication is the experience of
successful control of symptoms by medication. If
medication controls symptoms in the way a
patient wants, then attitudes are likely to change
positively. Charlton found that as morbidity
improved negative attitudes to asthma decreased
[41]. The experience of unsuccessful control by
medication is likely influence patient negative
attitudes to medication. Studies still continue to
show that asthma is often under managed in
primary care. Allen et al. [46] carried out a
randomised trial of adult self-management inter-
vention, with a community sample of 116 general
practice patients. Knowledge and compliance
increased significantly in the intervention group
but morbidity did not change. The authors con-
cluded that this lack of change was due to the
high level of under management in the sample.
Only 16 of the total 116 participants were rated
at 12 months as having adequate asthma treat-
ment. Positive attitudes to using medication are
unlikely to be maintained if the burden of
regular use is not rewarded by symptom control.
7. Conclusions
People with asthma have conflicting attitudes
to using any medication regularly. Attitudes are
influenced by friends, family and the media, as
well their own experience that a medication
works successfully for them. Medication anxieties
will not be necessarily resolved by reassurance
about safety of inhaled or tablet steroids. Pa-
tients do not always see their doctors as disinter-
ested in giving advice about medication.
Inhalers that are easy to use are likely to
improve positive attitudes to medication. Tablet
medication may also be more acceptable to
patients than standard metered dose inhalers.
Attitudes are likely to be influenced by patient
experience of successful control, in ways that
work for them. Quality of life improvement, and
symptom control is probably more influential in
changing attitudes to medication than change in
lung function alone. It may not be necessary to
focus on changing attitudes in order to develop
successful control. Attitudes may change as a
result of successful control. Behavioural inter-
ventions for aiding self-management produce
better control. These interventions combine good
patient information, clear instructions, and the
chance to discuss anxieties and concerns about
treatment for asthma.
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