The Influence of Socioeconomic and Psychological Factors on Patient Adherence to Self-Management Strategies: Lessons Learned in Asthma
Patient adherence to self-management strategies is a major issue in asthma, as in other chronic diseases. Adherence should not be defined exclusively in terms of medication use, but the more behavioral aspects of self-management such as avoidance of aggravating factors and risk behaviors, disease monitoring, alterations in therapy according to level of disease control and initiating emergency action when required, need to be considered. There are different forms of non-adherence and many patients undertake some form of cost-benefit analysis with respect to treatment. Furthermore, adherence is not an `all or none' phenomenon and the level of adherence may vary between different aspects of management of a condition and over time. While asthma self-management strategies are undoubtedly effective, many patients make serious self-management errors during an attack and do not put into practice the self-management knowledge they possess. In asthma, adverse social, economic and psychological factors are common and these may have detrimental effects on self-management at different levels; health seeking behavior, in terms of the ability to benefit from self-management education, adherence to self-management strategies and in the ability to self-manage exacerbations of asthma. These adverse factors vary between patients and their influence may be subtle and insidious. Although a seemingly fundamental requirement for self-management, not all patients want an active role in disease management. The patient's willingness to participate needs to be assessed and strategies adapted accordingly. Because of the variety of adverse influences, all strategies to improve adherence need to be individualized. Provision of appropriate pharmaceuticals and good quality ongoing medical care are necessary prerequisites to any self-management strategies. It is important for the healthcare professionals involved to recognize and taken into account, but not necessarily solve, the individual adverse social, economic and psychological factors when providing advice. An ongoing therapeutic alliance needs to be established between the patient and the healthcare professional; `the clinician as a good listener and teacher'. This involves ascertaining the patients concerns about their illness and its management, and addressing these issues. Self-management education (and self-management generally) needs to ascribe to the five R's: Relevant to the individual, Realistic goals, Readily available, Reinforced and Refined over time. Optimal use needs to be made of the `teachable moment' and involvement of a wide range of persons in management (including peers) needs to be considered. While the self-management strategies need to be individualized, they can be augmented by generic material.
Asthma, Patient education, Pharmacoeconomics, Socioeconomic status
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