Australia has one of the highest national indices of asthma severity, and, paradoxically, one of the poorest rates of adherence with optimal medication regimens.1 The establishment of asthma as the sixth National Health Priority Area in Australia recognises this sizeable disease burden.2
Optimal care for many chronic diseases is provided by clinicians in an environment of "therapeutic partnership".3 Thus, an exploration of the breadth and nature of the burden of disease in patients' lives is of practical help to clinicians in understanding likely impediments to care. Such knowledge may be gained by qualitative research techniques.4
Our study, which was predominantly qualitative, aimed to understand the experiences of people with asthma and their families, and to explore how these experiences might influence asthma care in an Australian context.
We aimed to study people with asthma not controlled by their current therapy, and our sample was selected to represent a range of asthma severity and geographic locations. All patients aged 18–70 years who attended a public hospital emergency department for asthma (at a tertiary teaching hospital or a suburban hospital during March and April 2000, and a rural hospital in July and August 2000) were sent a letter about the study. They were then contacted by telephone to arrange an interview. Some were declared "uncontactable" after 10 attempts to call them at different times of the day were unsuccessful.
Our study was approved by the ethics committee of each hospital and written informed consent was obtained from each participant.
We collected demographic data, and participants completed a respiratory health questionnaire (adapted from the European Community Respiratory Health Survey)5 and a validated asthma knowledge questionnaire.6 We then conducted a semi-structured in-depth interview, exploring participants' history of asthma, previous health system experiences, medications, costs of treatment and the impact of asthma on their lives. Interview transcripts were returned to participants for confirmation of accuracy.
We examined participants' medical records and used Australian Asthma Management Guidelines in determining chronic asthma severity, which is predominantly based on medication use prior to emergency presentation.7
Participants' occupation groups were assigned according to the general categories of the Australian Standard Classification of Occupations (professional/managerial, clerical/sales/service, blue collar, home duties, and retired/unemployed).8
Data analysis was performed as previously described.9 We recorded and transcribed the interviews, and examined them for emergent themes. The computer packages N4 and NVivo10 were used for data management, and we analysed demographic information and questionnaire data using the SPSS software package.11
Transcripts were initially read by all of us, and the broad emergent themes were discussed. One of us (D P G) performed the initial coding of the transcripts, but three of us (D P G, R A A and J A D) independently examined the coding and coded data for emergent themes, and then met to compare interpretations. We resolved disagreements by listening to the audiotape, and, after discussion, reached consensus. This process allowed for the incorporation of deviant cases into the emerging thematic constructs.
Two of us (D P G and M J A) performed the quantitative analysis. The analytical concepts were then presented to a reference group to confirm their face validity. The group included health professionals, asthma nurse educators and members of an asthma advocacy group.
1: Recruitment of eligible patients
Status |
No. (%) |
||||||||||
Participant |
62 |
(32%) | |||||||||
Gave consent but not interviewed |
13 |
(7%) | |||||||||
Not contactable |
65 |
(33%) | |||||||||
Refused |
43 |
(22%) | |||||||||
Died |
1 |
(0.5%) | |||||||||
Discharge diagnosis not asthma |
11 |
(6%) | |||||||||
Total |
195 |
||||||||||
Of the 184 eligible patients, 62 completed the interviews (Box 1): 23 (37%) from a tertiary teaching hospital, 29 (47%) from a suburban hospital and 10 (16%) from a rural hospital. The demographic characteristics of the participants are summarised in Box 2.
Box 1
Box 2
Participants' demographic characteristics (n = 62)
Participants' asthma history is given in Box 3. Nearly two-thirds of participants (40; 64%) had seen a doctor for asthma within 4 weeks of their presentation to the emergency department.
Box 3
Participants' asthma history
Thirty-nine participants (63%) stated that the cost of asthma treatment, including medication and health services, was of concern to them. This was irrespective of whether or not they had a Health Care Card. The prescribed asthma treatments for participants varied widely, and this had clear implications for their medication costs.
The capacity to afford medication often determined treatment choices. In particular, 28 participants (70%) had co-morbidities and required multiple medications. They had developed ways of managing costs, such as not buying medication ("It was an extra $30") or lowering doses to prolong medication use (Box 4). It was apparent that, for four men, decisions to reduce the use of preventive medication based on cost were likely to have caused their hospital presentation.
Box 4
Excerpts from interview — financial and physical costs of therapy
Side effects of asthma medication were a concern for 45 participants (73%), and their perception of the risk of side effects influenced self-management decisions. Participants, particularly those who perceived their asthma to be mild or episodic, made their own judgement as to whether the side effects of medication were a greater risk than another asthma attack. This comment by a man in his 60s classified as a manager/professional with mild asthma is representative.
I would take the medication if I knew what was in it, and I understood it, and I knew that it wasn't going to shorten my life by any more than say 10% or 20%, or something like that.
Side effects causing concern included tremor, mouth or throat soreness, hoarseness, change in skin or body appearance, osteoporosis (now or in the future), or other side effects less clearly related to the recognised pharmacological effects of steroids (Box 4).
The decision to visit a doctor was influenced by costs, the necessity to take time off work, travel and waiting times, and the anticipated benefit. The cost of seeing a doctor was raised as an issue by 11 participants (18%), and several stated that they could not consult a doctor or specialist if they were not "bulk billed" (Box 5).
Box 5
Excerpts from interview — decision to see a doctor
Fourteen participants (23%) stated that their employment had been affected by their asthma. Participants described losing their jobs, changing their jobs, or losing income as a consequence of asthma. In some, a cycle was identified of illness due to asthma, diminished work opportunities, and subsequent loss of income (Box 6).
Box 6
Excerpts from interview — financial and employment costs
Questionnaire responses indicated that most participants had lost days from work and other normal activities in the past 12 months because of asthma. Only 17 participants (27%) reported no days lost, while 11 (19%) reported more than a month lost because of asthma. Not surprisingly, time off work was related to asthma severity, with 63% of participants with severe asthma (19/30; data missing for two participants) losing more than a week from work or usual activities in the past year because of asthma, compared with none of the 15 participants with mild asthma. This difference was statistically significant (Fisher's exact test, P = 0.001).
Interviews indicated that participants managed their asthma and work in several ways. Some spoke of choosing flexible employment, such as casual work, so they would not be obligated to work when ill. Others described "trying to last", or "soldiering on" in spite of their asthma (Box 6).
Participants spoke of the emotions of fear and panic associated with experiencing an attack of asthma. The potential impact of an asthma attack influenced decisions about holiday destinations or where to dine out (Box 6). Several participants also spoke of how asthma had affected their emotional and physical relationships with their partners.
Participants were acutely aware of the impact of their asthma on relationships. They recognised that during an attack of asthma, family members and even friends took on a caring role, which might result in their absence from school or work. They stated that "the scars and stress" for parents and siblings were often greater than their own. ". . . it's a lot harder for them . . . because they have to watch. . . . They are the ones who live on the bedside wondering if I'm going to survive".
A common theme was the role change from wanting to be independent of help when well to needing assistance from family and friends during an attack. During severe exacerbations of asthma, several participants mentioned that they liked someone else, such as a family member, to make decisions for them about whether to attend hospital or to call an ambulance (Box 6).
We studied the perspectives of people attending an emergency department for asthma, and the impact of the illness on their lives. In this group, the impact of asthma on daily life was broad, affecting personal and family life, employment and finances. Some participants performed their own "cost–benefit analysis", weighing up expense, perceived side effects and potential benefits of their medications. As a consequence, a significant proportion chose to alter medication doses or not to take prescribed medications. Our study further suggests that, for some, asthma contributed to their low socioeconomic status through diminished employment opportunities. We also confirmed previous findings about autonomy and independence in relation to severe illness in patients with asthma.12
Compared with current estimates of 6% of patients with asthma in Australia having severe disease,13 our study sample included a greater proportion of individuals with severe asthma. Our findings therefore apply particularly to those with severe asthma, a group which consumes the most resources for asthma care.2
Our results reflect the range of opinions and experiences of the participants; quantitative expression of our data would not accurately reflect prevalence.14 However, the strength of the themes that emerged was partly indicated by the number of participants stating such an opinion. Moreover, the breadth of our findings is underpinned by our comprehensive recruitment strategy, and our data collection and analysis conforms to best practice in qualitative research.15
Previous studies of the burden of asthma have relied on economic techniques to quantify costs.16,17,18 A National Asthma Campaign Report19 made extensive efforts to quantify both direct and indirect costs of asthma, with estimates ranging from $586 million to $718 million per year. However, such data do not reveal personal perspectives. A previous study estimating the impact of asthma on a broad range of life themes highlighted the economic effects of asthma.20 Our study supports such findings, and further amplifies the mechanism of the economic disadvantage experienced by people with asthma resulting from reduced job opportunities.
Asthma treatments, particularly inhaled steroids, have been shown to be cost effective in moderate and severe asthma, when the costs of therapy are offset by a reduction in hospital costs.21,22 Despite Australian Pharmaceutical Benefits Scheme subsidies, the cost of asthma medication was still reported to be a major issue by our participants, and is a likely important reason for poor medication adherence. To achieve optimal adherence, doctors need to ascertain their patients' perspective of the affordability and acceptability of medication. Our study further suggests that, in relation to total health expenditure for asthma, increasing copayments under the Pharmaceutical Benefits Scheme may be counterproductive — decreasing medication adherence and precipitating emergency presentations and hospital admissions.
Efforts to improve asthma care are unlikely to be successful if, from an individual perspective, the costs of therapy outweigh the known benefits of readily available treatments.23 We urge doctors to explore and engage with patients' "real" burden of asthma to achieve a therapeutic partnership, and facilitate improvement in health outcomes of people with asthma.
Received 10 December 2001, accepted 26 June 2002
Abstract
Objectives: To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.
Design: A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.
Setting: A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.
Participants: Sixty-two participants (19 male and 43 female), aged 18–70 years.
Results: The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost–benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.
Conclusions: To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.