Table 2 Issues around medications

Concerns over safety and side-effects of asthma medicines

• Some patients and carers believe asthma medications are unsafe, have side effects, decrease in effectiveness over time, and lead to long-term dependence^{23,28,29,30,32,36,40,48,62,64,66,72,73,74} (P/Ca/Ch). Despite this, patients and carers believe asthma medicines are necessary^62,68 (Ca).

• Patients have most concerns about steroids, due to side effects such as weight gain^24,34,54 (P). HCPs believe short-acting beta-2 agonists (SABAs) are overused, but some patients and carers, including adolescents and those from ethnic minorities and with intellectual disabilities, are reluctant to use ‘too much’ medication, viewing them as “toxic”, and fearing tolerance and addiction might develop^{23,30,32,33,36,60,73} (P/Ca/Ch).

• Some older patients with a longstanding diagnosis of asthma were reluctant to use their reliever medication due to side effects (tremor, palpitations) or believing their symptoms were not bad enough to warrant use⁵⁷ (P).

• Some patients are reluctant to use medication on a regular basis, so use preventative medicines inconsistently^24,68 (P).

• CAM medications are viewed as safe whereas conventional medicines are viewed as unsafe. CAM should be used alongside rather than instead of conventional medication²³ (P).

Overprovision of asthma medications from the HCP

• Some patients and carers are reluctant to follow GP treatment plans that include high dosages of preventer medications^{21,28,48,52,74} (P/Ca). They believe high dosages have limited benefits and are not useful^21,48 (P/Ca).

• Some carers do not like GPs experimenting with dosages that involve increases⁷⁵ (Ca).

• If patients perceive their doctor’s plan to be “too drastic” (i.e., if they view a prescribed dose of prevent medication as too high, or advice from the HCP to seek emergency care as unnecessary), they adapt their own plan, based on their own experience of dealing with symptoms^55,72,73 (P).

Practical barriers to medication adherence

• Patients perceive inhalers as time-consuming to use²² and sometimes forget to take medications away on holiday. As a result asthma symptoms worsen²⁴ (P).

• Adolescents are reluctant to use inhalers if they have to leave class, take the inhaler without sufficient privacy or in front of strangers³⁶ (Ch).

• Some patients report problems accessing medications, due to costs of medications, insurance coverage, problems obtaining refills at the pharmacy, and having to travel long distances for medications^{36,39,41,43,73}. Some patients believe medicines are dispensed with incorrect instructions or medications by the pharmacist^22,24 (P).

• Costs of medication, not taking medication as prescribed, and not attending a medication review are potentially preventable factors that lead to ED re-attendance⁵⁶ (R).

• Some carers/ patients were too busy to remember to use PEF⁶⁵ or medications^24,29,72, and some parents skipped doses to avoid upsetting their child⁷² (Ca/P).

• Although health care providers feel they are clear about the differences between controller and rescue inhalers, many patients do not know the difference. Some older adults and adolescents misunderstand how often to use controller medication^39,40,42 (HCP/P).

• Some adolescents, and carers including school staff report difficulties in administering medications during school hours^28,31,34,42 (Ca).

• Patients, including those with intellectual difficulties, reported physical difficulties using some devices and inhalers^39,60,73 (P).

Trial and error approach to medication management

• Some patients and carers use a trial and error approach to taking their medications (by stopping or reducing medications). They test whether they still need medications and adjust medications according to symptoms^{11,22,29,51,75} (P/Ca).

• Some patients see this experimentation as ‘not bothering’ the doctor¹¹ (P).

• Patients, including african american young adults and carers who perceive themselves/their child as not having asthma typically use this approach, reducing their medication when symptoms improve^30,43,50 (P/Ca).

• Trial and error can lead to worsening of symptoms, causing patients to perceive that preventative medicines are not necessary^11,22, or effective⁵⁴ (P).

• Trial and error approaches are based on health beliefs and past experience, and can occur in collaboration with the GP, increasing patients’ confidence in self-managing their asthma^40,42,57 (P/Ca). Professional advice is tested and adapted to fit in with patients’ and carers’ understanding and beliefs of whether symptoms are ‘tolerable’ ^51,52 (P/Ca).

• Some carers use trial and error approaches to decide whether their children need to continue taking inhaled corticosteroids⁵¹ (Ca).

Reasons for/against CAM use

FOR:

• Patients who were more interested in and positive about CAM tended to be female⁷³ (P).

• Many patients and carers use CAM to be in control of medication rather than feeling dependent on it^49,56,75 (P/Ca).

• Those who use CAM believe it gives them a more tailored treatment approach that is: 1) effective, natural and non-invasive, 2) good for mild symptom control, and 3) safer than conventional medicines^23,48,66 (P).

• Many CAM users believe the combination of CAM and Western medicine is superior to either approach used alone⁷³, as it results in improved effectiveness of rescue bronchodilators²² (P).

• Some carers believe CAM improves immunity^64,65 (Ca).

AGAINST:

• Some patients think CAM medicines are ineffective in managing asthma, (i.e., ‘severe’ symptom control) and there is a lack of scientific evidence recommending many of them^45,48 (P).

• Some CAM approaches were strongly advocated, but were also labelled as too time consuming⁷³ (P).

Preference for medications by patients

• Some carers prefer their child to take a particular type of medicine (e.g., nebuliser or the metered dose inhaler)²⁹ (Ca).Carer and patient preferences were often based on habit, method of administration they felt most effective, confusion surrounding particular medications, side effects perceived and fear of taking too many medications^26,30,74 (Ca/P).

• Carer and patient preferences were often based on habit, method of administration they felt most effective, confusion surrounding particular medications, side effects perceived and fear of taking too many medications^26,30,74 (Ca/P).

Facilitators of medication use

• A number of strategies were used to remember when to take medications, including visual cues, reminders, setting phone alarms, and matching to routine daily events^40,62,72 (P/Ca). This was particularly the case for those with intellectual disabilities and caregivers of African urban teens ^34,60 (P/Ca). A proactive attitude was also a facilitator⁶² (P).

• Adolescents are more likely to use inhalers if it is nearby, and they are able to use it without disrupting activities, with sufficient privacy, and with support from friends, teachers and coaches³⁶ (Ch).