Asthma Treatment Adherence and Related Factors in Shanghai, China
Asthma is a prevalent chronic respiratory disease affecting approximately 300 million individuals worldwide. Despite its widespread impact, at least 50% of both adults and children with asthma do not adhere to their prescribed control medications. Poor adherence to asthma treatment is a significant contributor to uncontrolled symptoms, exacerbations, and hospitalizations. Understanding the factors influencing adherence and implementing strategies to improve it are critical for achieving optimal asthma control. This study aimed to investigate medication adherence and its associated factors among asthma patients in Shanghai, one of China’s most developed metropolises, to identify potential interventions for improving asthma management.
Study Design and Methodology
This multi-center cross-sectional study was conducted in four tertiary hospitals and six secondary hospitals in Shanghai. Participants were outpatients diagnosed with asthma for at least three months, aged 18 years or older, with basic communication abilities, and capable of completing the study questionnaire. Ethical approval was obtained from the ethics committee of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, and all participants provided written informed consent.
The study utilized a specially designed questionnaire to assess asthma medication adherence. The questionnaire included sections on sociodemographic characteristics (age, gender, education level, and type of outpatient service), disease awareness, asthma medication use within the previous month, and the eight-item Morisky Medication Adherence Scale (MMAS-8). The MMAS-8, a validated tool for evaluating medication adherence, assigns a total score of eight points, with scores below six indicating poor adherence and scores of six or above indicating good adherence. Additionally, the questionnaire explored 13 potential reasons for poor adherence, based on previous studies and clinical experience.
Participant Characteristics and Adherence Rates
A total of 552 valid questionnaires were collected. The participants were divided into two groups based on their MMAS-8 scores: 275 patients (49.8%) were classified as having poor adherence, while 277 (50.2%) demonstrated good adherence. Analysis revealed that younger patients (aged 18–30 years) had significantly lower adherence rates compared to those over 50 years old. Furthermore, patients treated in specialist clinics exhibited poorer adherence than those treated in general or expert clinics. Although not statistically significant, patients with higher education levels (university or above) showed a trend toward poorer adherence compared to those with lower education levels (junior high school or below).
Disease Awareness and Its Impact on Adherence
The study assessed participants’ knowledge of asthma using five specific items. The correct response rates for these items were 79.9%, 61.6%, 50.5%, 52.2%, and 40.4%, respectively. Only 30.4% of participants answered all five items correctly, while 19.6% knew three to four items, and 50.0% knew two or fewer. Patients in the poor adherence group demonstrated significantly lower awareness rates for four of the five items, with the exception of item 3. Additionally, a significantly higher proportion of patients in the poor adherence group knew two or fewer items compared to the good adherence group.
Medication Use Patterns and Adherence
The study also examined the types of medications used by participants and their relationship to adherence. Patients in the poor adherence group were more likely to have been prescribed short-acting bronchodilator inhalers, combined oral compound methoxyphenamine, and traditional Chinese medicine. They were also more likely to use four or more types of medication compared to the good adherence group. These findings suggest that non-standard treatment regimens and the complexity of medication use may contribute to poorer adherence.
Reasons for Poor Adherence
Participants identified 13 potential reasons for poor adherence. The most commonly cited reasons were self-defined symptom improvement (31.9%), forgetting to take medication (24.5%), inconvenience of buying medicine (21.2%), reluctance to use inhalers over a long period (17.2%), fear of drug dependence (16.7%), unreasonable drug prices (15.9%), difficulty of long-term persistence (14.9%), fear of side effects (9.1%), financial difficulties paying for medicines (5.6%), finding it hard to use the device (5.4%), inability to buy medicines continuously from the hospital (4.7%), poor self-perceived efficacy (3.6%), and inconvenience of carrying the device (2.7%). Patients in the poor adherence group were significantly more likely to cite self-defined symptom improvement, forgetting to take medication, reluctance to use inhalers over a long period, fear of drug dependence, difficulty of long-term persistence, finding it hard to use the device, and poor self-perceived efficacy as reasons for their non-adherence.
Discussion
The study highlights several critical findings regarding asthma treatment adherence in Shanghai. Despite being one of China’s most developed cities with a robust healthcare system, only 50.2% of asthma patients demonstrated good adherence to their prescribed medications. This rate is concerning, particularly given the city’s advanced medical infrastructure. Younger patients (aged 18–30 years) exhibited significantly lower adherence rates than older patients, suggesting that younger individuals may not prioritize asthma management. This finding aligns with previous research indicating that young adults are a high-risk group for poor treatment adherence.
The study also revealed that patients treated in specialist clinics had poorer adherence than those treated in general or expert clinics. This unexpected finding suggests that specialist clinics may not be effectively fulfilling their role in asthma management. In contrast, expert outpatient clinics, which typically limit the number of patients to ensure adequate clinician-patient interaction, demonstrated better adherence rates. This underscores the importance of effective communication between healthcare providers and patients in improving adherence.
Disease awareness emerged as a significant factor influencing adherence. Patients with poor adherence had lower knowledge levels about asthma and its treatment, particularly regarding the necessity of long-term and sustained therapy. This finding is consistent with previous studies, which have identified a lack of understanding about the benefits of long-term treatment as a major barrier to adherence. Improving patient education and awareness is therefore a critical component of enhancing adherence and asthma control.
The study also identified specific medication use patterns associated with poor adherence. Patients prescribed short-acting bronchodilators, non-standard treatments (e.g., oral compound methoxyphenamine or traditional Chinese medicine), and those using four or more types of medication were more likely to exhibit poor adherence. These findings suggest that non-standard and complex treatment regimens may hinder adherence, possibly due to the temporary relief provided by short-acting bronchodilators or the increased difficulty of managing multiple medications.
The reasons cited by participants for poor adherence provide valuable insights into the challenges faced by asthma patients. Self-defined symptom improvement was the most commonly cited reason, indicating that patients may discontinue or reduce their medication when they perceive their symptoms to be under control. This highlights the need for healthcare providers to educate patients about the importance of continued treatment, even in the absence of symptoms. Other significant barriers included forgetting to take medication, reluctance to use inhalers over a long period, and fear of drug dependence, all of which underscore the need for patient-centered interventions to address these concerns.
Conclusion
Asthma treatment adherence in Shanghai is suboptimal, with only half of patients demonstrating good adherence to their prescribed medications. The study identified several factors contributing to poor adherence, including younger age, treatment in specialist clinics, low disease awareness, non-standard and complex medication regimens, and patient perceptions about symptom improvement and treatment necessity. To improve adherence and asthma control, healthcare providers must focus on patient education, effective communication, and individualized treatment plans. Addressing these barriers will require a comprehensive approach that considers the unique needs and challenges of each patient.
doi.org/10.1097/CM9.0000000000001680
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