Enabling and hindering factors influencing adherence to asthma treatment among adolescents: A systematic literature review

Figures & data

Table 1. PICOS.

PICOS	Defined PICOS	Additional search terms
Population	Adolescents with asthma	Young people, youth, teenager, children
Indicator	Non-adherence to asthma treatment	Non-compliance
Comparison	Adherence to asthma treatment	Compliance
Outcome	Behavioral reasons for non-adherence	Determinants, personality, self-management, beliefs, concerns, barriers, health literacy, knowledge, education, support, parents, caregiver, peers, doctor, healthcare provider
Setting	Not limited	–

Table 2. Overview of included studies.

Author,						Definition		Limitations and
year	Location	Target Group	Disease	Aim	Methods	Adherence	Outcome	Overall Quality
Axelsson et al., 2013	Sweden	All ages n = 516	Asthma	Determine the mediating effects of beliefs about asthma medication between personality traits and adherence	Questionnaire	Not stated	Personality traits could be used to identify asthma patients who need support with their adherence behavior. Concerns partial mediator for influencing effects of agreebleness, conscientiousness, neuroticism	Self-reported adherence Sparse data on SES Good
Axelsson, 2013	Sweden	216 Young adults (22 years)	Asthma	Identify young adults stated reasons for not taking asthma medication	Questionnaire	Not stated	Important parameters for non-adherence to asthma treatment are negative affectivity and perceived asthma control	Selection bias Good
Bender, 2006	USA	Adolescents and young adults	Asthma	Reviews association between depression, risk behavior and nonadherence	Literature review	Not stated	New behavioral studies must be more well-designed in order to show a reliable associations and correlations	Not systematically Medium
Bourdin et al., 2012	France	All ages	Asthma	Discuss new definitions of therapeutic adherence in the scope of severe asthma, its assessment, the reasons for poor therapeutic adherence, and potential solutions	Review	The ability to take medication accordingly. A partnership between patients and healthcare provider	Adherence is a vast domain of competency where a pluridisciplinary approach is required.	Medium
Braido et al., 2010	Italy	Healthcare provider	Asthma	investigate physician-related factors that can influence successful asthma management	questionnaire	Not stated	level of GPs and asthma specialist regarding the use of asthma control tool was not optimal. Respondents were also unable to correctly identify the level of asthma control. A large majority did not believe in the effectiveness of self-management plans	Good
Bruzzese et al., 2004	USA	Adolescents	Asthma	discuss developmental transition in cognition, knowledge, autonomy, identity development, and peer relations in term of their influence on adolescents' asthma management	discussion about developmental transition of adolescents and its influence on asthma managementrandomized control trial of a school based asthma education program	Not stated	Adolescents are at higher risk for asthma and its negative consequences compares to children. The presented intervention was shown to be feasible.	Feasibility study. has not assessed efficacy of study Poor
Bruzzese et al., 2014	USA	168 adolescents	Asthma	Test the self-determination theory to explain adherence to asthma medication regimens in African American adolescents	Interviews	Not stated	Helping families to better integrate asthma care in daily schedules may be an important intervention strategy to improve medication adherence among high risk African-American adolescents.	Self-reported data Baseline date from larger RCT Medium
Chen at al., 2013	Taiwan	65 children (6–14 years) and caregiver	Asthma	Evaluated effectiveness of a self-management interactive support (SMIS) program for caregivers of children with asthma	Randomized Control Trial	Not stated	Interactive support interventions reinforce learning incentives and encourage self-care and adherence to therapeutic regimens	Short follow-up period (1 year)
Chen et al., 2007	Canada	Children and adolescents 9–18 years (n = 78)	Asthma	Test associations of neighborhood, peer, and family factors with asthma outcomes in youth and to determine the pathways through which these social factors operate	Questionnaire	not stated	family factors may affect youth's asthma via physiological changes, whereas community factors may help shape the health behaviors of youth with asthma	Self-reported adherence → bias cross sectional study design good
Corsico et al., 2007	12 countries	971	asthma	Identify factors affecting changes in asthma treatment adherence in an international cohort	Follow-up study, structured clinical interviews, questionnaire logistic model used to study adjusted effect of determinants	Not stated	Doctors and nurses have a key role in educating and regularly reviewing the patients. The findings support efforts for better improvement of clinical communication	Self-reports of adherence not most accurate method Good
Desai and Oppenheimer, 2011	USA	Children and adolescents	Asthma	Shed light on the frequency and forms of nonadherence in children and adolescents, its consequences and methods to monitor medication usage	Review	The extent to which a person's behavior, taking medication, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider	Adolescents and minorities appear to be at higher risk of non-adherence and increased mortality and thus require special attention and monitoring	Not a systematic literature review Medium
Edgecomb et al., 2010	UK	22 adolescents (11–18 years)	Asthma	Understand adolescents' health experiences with difficult asthma	Interviews	Not stated	Adolescents have a poor understanding of their medication and using it is often conflicted with other activities. They are very reliant on their parents.	Results may be biased through Hawthorne effect Medium
Foster et al., 2012	Australia	99 patients ages >14	Asthma	Identify potentially modifiable beliefs and behaviors that predict electronically recorded adherence with controller therapy	Questionnaire	Not stated	experienced side-effects and opinions of friends/family about patient's medication use associated with poor adherence. Other influencing themes are e.g.: perceived necessity, safety concerns, effectiveness, motivation, ease of use	Good
Guglani et al., 2013	USA	422 urban adolescents	Asthma	Assess self-reported symptoms of depression as an effect modifier of the relationship between randomization group and controller medication adherence at 6-month follow-up	Randomized control trial	Not stated	Interventions aimed at improving medical adherence need to be tailored to for adolescents with depressive symptoms	Did not identify which component of intervention instrumental in motivating participant to be more adherent Results may not be applicable to other population Medium
Harrington et al., 2013	USA	277 parents of asthma patients 14 healthcare provider	Asthma	Assess how healthcare provider perceptions of parental health literacy influences treatment recommendations and instructions	Questionnaire	Not stated	Healthcare providers' perceptions about parents' health literacy can influence treatment recommendations and instructional practices	study may not be applicable to samples that differ demographically Medium
Irwin and Richardson, 2006	USA	general	Asthma	Highlight the importance and effectiveness of patient-focused care	Review	Not stated	Patient-focused care has shown to improve adherence to medication. Communication, continuity of care and concordance are highly relevant for effective and should be a key component in asthma management	good
Lasmar et al., 2009	Brazil	Children and adolescents with asthma	Asthma	Assess rates and factors related to Poor adherence to ICS over time in asthmatic children and adolescents	Randomized cohort study	Not stated	Adherence rates decreased over time even if the medication was provided for free. Factors related to Poorer adherence change over time. adherence has a dynamic pattern wherefore its determinants need to be re-evaluated continuously	Data collection through pharmacy records is not very accurate Medium
Lindsay and Heaney, 2013	UK	All ages	Asthma	Explore the facts and myths surrounding the factors driving nonadherence as well as how it can be identified and addressed	Review	The extent to which a person's behavior corresponds with agreed recommendations from a healthcare provider	Nonadherence is difficult to identify. Therefore, the assessment of non-adherence is of paramount importance in difficult asthma management.	Medium
Mäkelä et al., 2013	Scandinavia (Finland, Denmark, Sweden)	all ages adolescents specifically mentioned	Asthma and COPD	identify reasons behind non-adherence to therapies for asthma and COPD and examine evidence for correlations between the correct use of inhaler devices and improved adherence	Literature review	The extent to which patients were perceived to follow their physician's prescribing instructions/advice	Electronic assessment of medical adherence is the most accurate method.	Literature search not rigorous. search terms very limited Medium
Mancuso and Rincon, 2006	USA	175 adults with asthma Mean age 42 83% women	Asthma	Measure association between HL and asthma outcomes And assess how HL affects asthma through covariates	Questionnaire Emergency department utilization measured every 3–6 months for 2 years	Not stated	Less health literacy was associated with worse quality of life, worse physical function, and more emergency department utilization for asthma over 2 years	Selection bias Medium
Mosnaim et al., 2014	USA	Adolescents (11–16 years)	Asthma	Identify factors associated with non-adherence to daily ICS in minority adolescents	Questionnaire	Not stated	Older age and Poor ICS knowledge are both associated with poor adherence to ICS in minority adolescents.	No control group Other factors that affect adherence were not considered Poor
Munzenberger et al., 2010	USA	104 Caregiver and child (7–17 years of age) pairs	Asthma	Explores the relationship between children, caregiver, family, and asthma charcteristics and responsibility for self-management activities.	Interview and chart review	Not stated	Responsibility for asthma management task is perceived differently by caregiver and children.	(Sample not generalizable) Study did not explore relationship between perceived level of responsibility and actual adherence Poor
Orrelle-Valente et al., 2008	USA	Children and adolescents (age 4–19)	Asthma	Examine [1] association between child age and extent of daily controller medication responsibility [2] role of caregiver in this [3] association between child's medication responsibility and overall adherence	Telephone survey with 351 parents	Not stated	Medication responsibility increases with age. child's age and parents race/ethnicity are significantly associated with medication adherence	Parents were asked about their children's behavior towards asthma medication responsibility and adherence. not accurate Medium
Petermann, 2004	Germany	All ages	Asthma	Overview of facts regarding the characteristics, costs and consequences of non-compliant behavior	Summary of main facts	Uses the word compliance: The extent to which patient's behavior corresponds with the recommendations of the healthcare provide. It is complex, dynamic and situation-dependent.	Non-compliance leads to high costs for the healthcare system. Improved doctor-patient relationship and education leads to better self-management of asthma and hence better health outcomes	PoorBased on the author's work mainly
Petteway et al., 2011	USA	835 elementary aged children (up to 15 years) and caregiver	Asthma	Described association between peer interactions and asthma related emotional experience, asthma control, and outcomes	Exploratory study (interviews)	Not stated	Providing children with communication strategies for disclosure of asthma status to peers that results in more supportive interactions may be needed	Sample predominately African American; findings not generalizable, emotional concepts and terms used were not tested for target group's level of understandingMedium
Price and Thomas, 2006	UK	Asthma guidelines	Asthma	Review the limitations of current asthma guidelines and describe important issues and remaining questions regarding asthma guidelines for use	Review	Adherence to physicians' recommendations	Country-specific or ideally local guidelines could provide more practical solutions for asthma care that influence patient choice and adherence to therapy.	No systematic review Poor
Rastogi et al., 2013	USA	268 caregivers of ethnic minority children with asthma	Asthma	Assess whether educational interventions for parents decrease emergency department visits and hospitalization	Randomized Control Trial	Not stated	Those who underwent the intervention had fewer emergency department visits two years after the intervention	Selection bias Medium
Rhee et al., 2010	USA	126 adolescents (13–20 years)	Asthma	Examine the role of barriers to adherence in mediating the effect of family support in asthma outcomes	Questionnaire	Patient's range of behaviors such as taking medications […] that align with medical and health advice to achieve optimum health outcomes.	Family support is beneficial for improving asthma outcomes in adolescents. It ameliorated the barriers to treatment adherence	Good
Rosas-Salazar et al., 2012	USA	Children and adults	Asthma	Raise awareness of the problem of Poor health literacy and asthma health outcomes, summarize current evidence linking health literacy and asthma, offer strategies to strengthen communication between patients and healthcare providers	Literature review	Not stated	Poor health literacy is a key barrier to asthma knowledge. Poor parental health literacy is associated with poor outcomes for their children	Methods were Not stated Medium
Shone et al., 2009	USA	Parents of children with asthma	Asthma	Examine association between parental health literacy and measures related to child asthma	Interviews	Not stated	Poor parent health literacy was independently associated with greater parent worry, parent perception of greater asthma burden and Poorer parent-reported quality of life	Selection bias (Poor HL, Poor income) Sample limited in asthma severity Medium
Stewart et al., 2011	Canada	44 mothers of children with asthma (4 – 16 years)	Asthma	Parents' intervention preferences were elicited. Based on this an online peer support group intervention was designed and piloted	Interviews (N = 44) Pilot intervention (N = 23)	Not stated	Parents prefer support interventions for children and parents in order to interpret available information and apply it in their situation.	Small sample size for pilot study Medium
Stewart et al., 2011	Canada	20 children (6–12 years) 35 caregivers	Asthma	Assess the support and education needs and preferred intervention	Semi-structured individual interviews	Not stated	Parents and children prefer a combination of in-person meetings and internet support	Good
Terpstra et al., 2012	USA	middle school youth	Asthma	Evaluation of a pilot asthma management intervention of middle school-ages youth and their adult network members (caregiver)	Randomized control trial	Not stated	Intervention increased caregivers' self-efficacy and adolescents sense of responsibility	Selection bias: only those took part who agreed to participate Differences at baseline between both groups Medium
Tibosch et al., 2010	The Netherlands	339 Children and adolescents (6–16 years) and their caregiver	Asthma	Assess relationship between asthma related QoL and psychosocial problems	Questionnaire	Not stated	Prevalence of psychosocial problems in children and adolescents with asthma is considerable. They affect medication adherence. Assessment of asthma related QoL alone is insufficient.	Good
Ting, 2004	USA		Asthma	Use of simplified asthma tools to improve asthma care	Review	Not stated	NAEPP and GINA asthma guidelines are too complex for daily use, whereas the MSAGR is more user friendly.	Medium
Tumiel-Berhalter and Hershey, 2005	USA	Medical directors of 13 academic primary care sites	Asthma	Provide a descriptive account of the preparedness of academic primary care sites to folPoor national asthma guidelines	Cross-sectional (questionnaire)	Not stated	The findings highlight the importance of the practice environment on the implementation of national guidelines	Limited generalizability Medium
Ulrik et al., 2006	Denmark	509 adults between 18 and 45	Asthma	Explore patient-related aspects of adherence among adult asthmatics	Online questionnaire	Non-adherence: deliberate deviation from recommended therapy. The authors differentiate between intentional and accidental non-adherence.	Lack of perceived symptoms main reason for non-adherence. reasons for suboptimal adherence seem to be accessible through education of patients and caregivers.	Selection bias: online questionnaire (selected group from a panel who replied) Poor
Van Steenis et al., 2014	The Netherlands	93 (18–80)	Asthma	Investigate relationship between beliefs about asthma medication (ICS) and measure adherence (subjectiveley and objectively) and teh agreement between these measures.	Questionnaire	Not stated	High necessity is associated with higher self-reported adherence	Selection bias (high educational level of participants, while among majority of Dutch asthma patients only 24.2% highly educated); only data from pharmacy used Medium
Wamboldt et al., 2011	USA	26 adolescents (12–20 years)	Asthma	Examine beliefs, feelings, and behaviors about inhaled asthma controller medication	Focus group interviews	Not stated	A variety of beliefs, feelings and behaviors influence decision about asthma medication use. misinformation, incorrect assumptions about their asthma and current life situations lead to poor adherence.	Selection bias (participants with high IQ and parents with high educational attainments) Good
Yang et al., 2010	UK	Young adolescents 9–14 years 86 parent-adolescent dyads	Asthma	Investigate the association between social support variables and healthy lifestyle for asthma management among early adolescents	Questionnaire	Not stated	The developmental change of social support during early adolescence need to be recognized	Some omitted variables that hamper internal validity. other aspects of social support remain uninvestigated in this study such as adolescent's relationship with parents Other relevant variables missing (i.e., self-efficacy) Poor
Yawn, 2008	USA	All ages	Asthma	Reviews recent articles dealing with asthma variability, environmental factors, and co-morbidity that affect asthma control	Review	Not stated	Co-morbidities have a significant impact on asthma variability. Documenting asthma variability and adherence can lead to the development of treatments that can anticipate the level of symptoms	Poor Only one data base was used and only recent articles included.
Zebracki and Drotar, 2004	USA	77 adolescents 11–17 years and their caregivers	Asthma	Relation of outcome expectancy and perceived self-efficacy for asthma prevention and management in adolescents to asthma self-management, adherence to treatment and asthma morbidity	Questionnaire and interviews	Not stated	High outcome expectancy was associated with greater asthma morbidity but unrelated to self-management or treatment adherence. Self-efficacy was related to treatment adherence but unrelated to asthma morbidity or self-management	Self-reported adherence Correlational study, wherefore causal inferences are precluded Good/Medium

Figure 1. Flow chart (adapted from PRISMA 2009 Flow Diagram).

Figure 2. Overview of enabling and hindering factors.

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