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However, perceived stigma regarding asthma leads to reduced adherence to medications, particularly in public. Similar findings have been reported regarding medication adherence and negative views of asthma. These findings emphasise the importance of patient acceptance of asthma diagnosis and how this influences asthma management. This has been reported in relation to successful management in other conditions. Text message, Internet, booklet, DVD, and pharmacist interventions were perceived as acceptable self-management programmes.

When consulted, patients report ways to improve interventions, which in turn might lead to improved self-management adherence. However, findings regarding action plan and guideline use are consistent with evidence that both healthcare professionals and patients hold negative views regarding the usefulness and practicality of action plans and guidelines, believing they are useful only for some people. An Asthma UK report on barriers to effective emergency asthma care also recommended promoting awareness of guidelines by "signposting" patients to charities and.

Patients' health beliefs and illness representations30 can be a barrier to care and SM, directly influencing how they manage asthma24,28,32 R. Many carers including Taiwanese mothers use the occurrence of asthma attacks, symptoms and behavioural change to assess the asthma51,66 Ca. They may deny their asthma or minimise its severity23,53,62, forget medications29 and not follow action plans55 P.

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Text message mobile technology might help some patients accept and come to term with their diagnosis47 P, HCP. Disliking feeling out of control with symptoms is a motivator for gaining and maintaining control22,67 P. Carers do not want asthma to be used as an excuse to not do particular things, i. Some were not motivated to act until it posed a life threatening state59 P.

Treating only symptoms that bother the carer, instead of self-adjustment of medication in line with action plans, goes against GP advice70 R. Carers and children hold differing views of how to be responsible for managing their asthma53 R. Some children report awareness of triggers and tell someone when they feel unwell26 Ch. Transfer of responsibility from carer to child in managing asthma is gradual,34,53 and negotiated29'34 Ca, R. Many Taiwanese carers are fearful when children start school, as they will be unable to manage their child's asthma during school time.

Parents have concerns over balancing monitoring medication use and encouraging independence feeling children should take responsibility in case they are not around.

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Some nurses suggest involving children in consultations to show their carers they are becoming independent52 HCP. School staff are often unclear how to manage asthma, with some being over cautious e. Others aim to learn to live with asthma30 Ca. Some caregivers of urban African American teenagers instigated the development of an asthma action plan with their school nurse34 Ca.

Many HCPs plan ahead if they are expecting a child who will need school documentation including an asthma action plan39 HCP. Some adult patients reported peak flow monitoring to be 'nonsense' or 'frightening'73 P. African American women report that mood and memory problems can be a barrier to remembering to follow their asthma action plan35 P. Despite attending regular asthma reviews, some adults with asthma were sceptical about the interest, knowledge, and understanding demonstrated by GPs59 P. Some patients and GPs have low self-efficacy for using action plans.

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This mainly applies to patients who have not accepted their diagnosis55 and GPs who infrequently prescribe action plans69 P, HCP. Some patients feel action plans need to be 'modified' in some way unspecified , to meet the needs of those with severe asthma61 P. Some patients saw it as useful for identifying triggers and monitoring symptoms50 P.

Some GPs believe it benefited their patients, in understanding asthma, reducing symptoms and improving compliance.


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They think it was also good for record keeping and performing calculations68 HCP. Adults and Older Adults found it.

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Young African American patients felt that an online programme with email and text messages would be helpful and desirable43 P. This group was more willing to use an electronic action plan and was not concerned about the time taking to monitor symptoms68,71 R. Issues not raised in previous reviews were patient reported mood and anxiety problems that can impair self-management, and having a comorbidity perceived by patients as more important to treat.

Research in our review identified that the use of non-pharmacological methods to delay medication use appears to be contributing to poor control. Perceived access to healthcare is also raised in this review and highlights the use of patient advocates to assist with issues such as difficulty getting appointments. This review includes mainly Caucasian patients with asthma, although some studies have explored the views of minority ethnic and other at risk groups. The majority of the issues uncovered still need to be explored further in these subgroups.

Also, although we used a wide range of search terms, we may not have identified all published qualitative studies.

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Overall, the quality of the reviewed studies was high. However, future studies should provide sufficient information to enable assessment of whether the researchers have adequately considered the relationship between researcher and participants, and whether ethical issues have been considered.

Implications for future research, policy and practice There are several areas that could impact on future research, policy and practice. With regard to practice, better adherence to asthma self-management may be achieved in a number of ways. First, evidence from our review suggested that educational interventions including mobile phone and internet interventions facilitated asthma self-management, and were perceived as acceptable and useful by HCPs and patients.

Therefore, some patients, carers, teachers and healthcare professionals may benefit from further education.


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    • However, as some patients lack confidence with computers, their skills should be assessed prior to referral to ensure they receive appropriate interventions. With regard to research, future self-management intervention trials aiming to increase adherence to medications and action plans should include tailored education on recognising asthma symptoms, triggers, how to recognise an attack, patient concerns and beliefs regarding medications and non-pharmacological methods; and the importance and necessity of preventative medicine.

    Patients should also be advised to adjust medication only in collaboration with their GP, as a trial and error approach can cause symptoms to worsen. A good relationship between the healthcare professional and the patient or carer facilitates asthma self-management. In practice, healthcare professionals should aim for continuity of care, so they are able to give consistent advice, be aware of the history, background mental health and co-morbidities , and personal circumstances of the patient such as social support networks.

    They should also try to understand the beliefs the patient and carer hold about asthma and their medications, as negative beliefs about medication may act as a barrier to effective self-management, and can be addressed if brought up in consultation. Patients often report comorbidities, both related and not related to asthma, which they are managing alongside their asthma. Therefore, managing their Asthma may not be their top priority21,24,35 P. Asthma symptoms and management can also constrain the management of co-morbid conditions e.

    Asthma can lead to low self-worth and the patient feeling different to others, leading to withdrawal from society. They may neglect SM and their health deteriorates50 R. Carers' emotion influences the emotions of their children75 R. Family members and significant others can upset those with asthma by their over- and under-reactions to the condition, and unhelpful behaviours e. Some South Asian patients may adopt a more passive approach to managing their asthma.

    Some white patients seem to take a more proactive approach to SM44 R. Some adolescents and young people can be reluctant to tell their friends about their asthma, preferring to use a need to know basis33,43 Ch. Adolescents with uncontrolled asthma used more of these methods and delayed using mediation longer36 Ch. These included complementary or alternative therapies e.

    Lifestyle changes were also used to attempt to improve asthma control. These methods include diet, weight. Patient advocates can help patients get appointments21,24 R. Patient advocates can help patients when they experience difficulties making appointments21 P, R. Issues include a lack of or limited health care resources such as, time restrictions during consultations, poor inter-professional communication between HCP and outside professionals, unclear roles, poor team work, and practical issues,.

    Third, some GPs had negative views regarding the usefulness of guidelines and action plans, so did not always use them to conduct evidence-based practice. This is a modifiable barrier to asthma self-management. The use of proformas to ensure patients undergo care that follows current guidelines has been suggested,1 and we concur with Asthma UK's recommendation of providing training to healthcare professionals to enhance feelings of competence in implementing guidelines.

    The fourth area is concerned with the professional and demographic features of the deliverer of the intervention. Evidence from this review suggests that nurses and AHPs are considered an effective source of information, so facilitate self-management. They could potentially be used instead of or in addition to doctors to deliver self-management interventions. Our review also provides evidence that pharmacist and patient advocate interventions facilitated asthma self-management. Fifth, cultural factors should be researched.

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    Our findings indicated that some Latino, African American, and South Asian patients perceive access to healthcare as an issue, and have poor understanding of their medications. However, education in using action plans increased confidence in some of these populations. These findings suggest that ethnic minority patients may need more tailored education to facilitate understanding of their medications. Future qualitative research is required to explore how barriers to effective self-management might differ according to ethnic background, and whether separate interventions presented in the patients' own language, and involving the family would benefit patients.

    The sixth area for future investigation is the age of the person with asthma, as different factors might influence intervention success in older and younger populations. Wider research suggests older patients are at risk of being non-compliant in taking medications. They may benefit from interventions focusing on education regarding acceptance of their.

    With regard to younger patients, this review suggests that in practice, involving children and adolescents in consultations, to show their carers how independent they are, could help facilitate the transfer of responsibility from the carer. As adolescents do not always take their asthma medications or attend asthma reviews, research could develop educational interventions possibly technological about the importance of this.