Asthma has been defined by many as; an inflammatory disease which is characterised by narrowing of the intrapulmonary airways but this is thought to vary across patients, (Pearson 1990; Conway 1995; Rees and Price 1995; Coakley 2000; Conway 1998). This is caused by biological changes in the muscle tone which can alter the relationship between elasticity and pressure. This results in a change in the diameter of the airways which can cause bronchoconstruction mucosal oedema, mucus secretion and bronchial hyper responsiveness, (Lazarus 1998 Coakley 2000). Hyland (2004) talks about the sequence of inflammatory mediators which results in over activity of the immune system. These can in turn equate to dyspnoea, cough and wheeze, (Conway 1998). The majority of asthmatics have mild to moderate symptoms of the disease, which can be controlled via pharmacotherapy, (Strachan 2000) but there is still no cure, (McAllister 2004). Multiple factors have been found which influence susceptibility such as; genetics, occupational risks, environmental variations. Links have been found between atopy and asthma however some asthmatics are not atopy, (Conway 1995)
It is estimated that asthma affects around 2 million people in the UK and prevalence rate is higher in older adults and young children, (Potterton 1992; Conway 1998). In 1994, there were 1600 deaths annually related to asthma, (Coakley 2000). Each year it is estimated that over 850 million is spent on asthma medication through the NHS, (McAllister 2004) The British lung foundation reported 450 billion on asthma medication, which was not being taken by patient which consequently contributes to death rates, (Pendleton 199; National Asthma Campaign 1996; Wilcock 1998; Conway 1998). Mortality rates are highest between the ages of fifteen and thirty four, one of the main reasons that contribute to high mortality rates could be a failure to adhere to treatment regimes. The British Thoracic Society (BTS) (1982) suggested that under treatment was the most significant cause of death. At present there is no specific diagnostic test that can ascertain for sure whether a person has asthma, instead patients are diagnosed when presenting with a history of variable airflow obstruction that responds to the treatments, as well as tests that indicate the disease, (McAllister 2004). Stress has been thought to induce asthma, this has led to misconceptions about asthma being purely psychological, but there are still researchers and healthcare professionals alike who believe it has a psychological element to it, (Logan 1992). Under treatment and non compliance is still ongoing. There is a great variability to the disease, with some in remittance for long periods of time, (Barbee and Murphy 1998). Under treatment is now recognised as a major contribution to the irreversible changes that occur in the pulmonary airways and permanent reduction in lung function, (Selroos et al 1995: Reed 1999) and chronically inflamed airways which predisposed to progressive lung disease as well as poor growth and development due to poor control, (Balfour and Lynn 1986).
Two directions of treatment are prophylactic and active; prophylactic is avoiding allergens, environmental cues and immune suppressants that provoke a reaction, however this is not easy for the atopic asthmatics. Active areas of treatment include pharmacotherapy and other alternative therapies, (Conway 1995). Until the early seventies only relievers were available; beta agonists ߲; which is now typically salbutamol or the blue inhaler. This drug wields an adrenergic effect on the sympathetic nervous system which results in the relaxation of the muscles and dilation of the bronchioles. Long-acting beta2 agonists, such as Serevent are also available on the market. Anticholinergics are a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system by inhibiting the vagal reflux which causes the bronchoconstruction. They act slower than ߲ but have similar effects and are typically recognised by the names of Atropine and Atrovent, (Conway 1995).
When corticosteroids were introduced they revolutionised asthma management by allowing steroids to be inhaled directly into the lungs in low doses which was sufficient to control the underline inflammation, producing a better level of control and less exacerbations for most sufferers (Barnes 1992; McAllister 2004; Pauwels et al 1997, Shrewsbury et al 2000). Inhaled steroids are thought to counteract irreversible asthma, (National Asthma Campaign NAC 2001). Inhaled steroids, also known as inhaled corticosteroids or ICS, come in different strengths and are generally used once or twice a day. ICS have been shown to decrease the production of substances called cytokines, which are produced by immune cells to generate an inflammatory response. The BTS/SIGN suggests the introduction of bronchodilators when the inhaled steroids fail to control the symptoms they are known as Methylxanthines and are a long term preventative which relies on systematic regimes. They work by inhibiting the release of histamines as well as relaxing smooth muscles. Leukotriene receptor antagonists (LTRAs) block the effect of crysteinyl Leukotrienes, powerful inflammatory mediators which are involved in asthma, (Drazen et al 1999; McAllister 2004).
Lack of knowledge is well documented reason for poor compliance rates, (charlon et al 1991) found a dramatic decrease in patient nebulisation 12 months after the introduction of a nurse ran clinic, (Conway 1995). It is suggested that 55% compliance is an optimistic view, 2/3 are expected to be non-compliant. Compliance is considered an obligation to yield passively to a request from a higher authority, such as being obedient with treatment regimes. Thus non compliance is the patients fault and evidence of unwillingness to obey advice. This diminishes autonomy when making decisions and reduces the possibility of joint problem solving based on mutual respect, (Conway 1998). Non compliance can be either deliberate; people who choose not to follow advice, perception of the disease may differ from that of a healthcare professional or that medication doesn't work or cost too much, (Wilcock 1998). Mistaken non compliance is characterised by using the medication incorrectly, why, when and how. This group is easily corrected through good education and well ran asthma clinics, (Conway 1995). White and Hewett 1991 found that poor compliance is related to morbidity rates. They found that when most asthmatics experienced little or mild symptoms they would forget or believe their medication was not needed, (Coakley 2000)
Adherence is individuals choosing to follow a plan or request, therefore it is a voluntary choice in which a commitment is made by a patient to follow a treatment plan. Non adherence is associated with guilt, a violation of their standards of behaviour. By inviting patients to assist in decision making rather than dictating treatment plans can in turn influence patient's decision making processes. This can be done in a number of different ways such as; Improving credibility, delivery of education, degree of report between healthcare professional and patient. Motivating the patient, providing effective consultation, the prescriber and patient should be on equal terms, (Pendleton 1991; Conway 1998). ICS are needed to be administered frequently and maintained; poor asthma is thought to be associated with non-adherence. However there is a large number of the asthmatic population who achieve good asthma outcomes with non adherence to medication. This may suggest that it may be beneficial for some asthmatics to learn to self medicate. Studies involving a dose recording electronic inhaler device identified common patterns, such as regular use, apparent hazard compliance and minimisation of the steroid use when reacting to symptoms rather than behaviour pattern, (Greaves, Hyland, Halpin, Blake and Seamark 2005).
Few studies have look at patterns of behaviour for non-adherent medication use as opposed to overall adherence rates. Hyland et al (2005) invited 294 participant to take part in a study investigating patterns of medication use. They identified six major categories; Regular users, Forgetting Low doses Symptom directed and the final two categories were non recordable due to a lack of data. Forgetting was apparently rare according to the results of the questionnaire; however doubts arise to the validity of the self report measures. The greatest non adherence was due to an intentional choice made by the patients to reduce treatment depending on their recent or current symptoms, (Hyland et al 2005).
Compliance has been considered as either; unwitting, erratic or Intelligent, (WHO 2003) Non compliance with medication have been liked to concerns about steroid preparation. Inhaled corticosteroids keep attacks at bay in used regularly but are useless during exacerbations and have side effects. Some side effects can be counterbalanced with other medication. Steroid phobia derives from an increased risk of glaucoma, acceleration of cataracts and a change in behavioural effects, (Coakley 2000). LTRAs are not steroids but have been improvements in lung function by blocking the leukotriene mediated bronchoconstruction. Oral LTRAs are advantageous for elderly and children. Future use is uncertain but it could be promising for some patients. Role of Leukotrienes; Singular (Montelukast) and Accolote (Zafirlukust). LTRAs; have fewer side effects, tablets are easier to take, new therapy so few scare stories, recommended as an add on therapy, however more research is needed as not all asthmatics respond to it, (for a full review see Coakley, 2000).
Williams (1993) proposed that any breathing difficulties can lead to extreme anxiety, frustration and depression. It should also be noted that those with severe allergic reactions with asthma may be presented with potential daily threats. Fear of death was deemed frequent and acceptable amongst those who were frequently admitted to hospital, (Alabaster 1995). Hunter (1995) believed that professionals should be aware of the complex issues surrounded asthma as well as being committed to improving strategies of care, (Morton-Cooper 1998). Hyland and Donaldson described feelings of learned helplessness and lack of control which can lead to a reduction in problem solving abilities, poor motivation, feelings of worthlessness and low self esteem. Treatment barriers such as education, language barriers, disease schema, conflicting advice, relationships, denial, cost, stigma, cultural and religious influences/restrictions, dislike of medication, side effects, complexity of regime, fear of addiction and emotional states, (Conway 1995).