We sought to determine the reasons for overuse of bronchodilator inhalers in a sample of young adults with asthma.
Twelve were high users of short-acting bronchodilators, nine were low users. High users of short-acting bronchodilators had adapted poorly to having asthma and expressed anger at the restrictions they experienced.
High users had poorer control of asthma and held explanatory models of asthma which emphasised short-term relief via bronchodilation over prevention. Both high and low users held strong views about having to pay for asthma medication, with costs cited as a reason for not purchasing anti-inflammatory inhalers. Young adults who were high users of short-acting bronchodilators had adapted poorly to having asthma and had poor asthma control. They gave coherent reasons for overuse. Strategies that might address high bronchodilator use in young adults include improving education to help young people accept and adapt to their illness, reducing stigmatisation and providing free asthma medication to encourage the use of anti-inflammatory inhalers.
Overuse of bronchodilators is internationally recognised as a marker of poor asthma control, excess healthcare use and asthma death—understanding the reasons for overuse is a key step towards developing interventions to address inappropriate inhaler use.
Elegant, purposive sampling design provides contrast between high and low users of bronchodilators. A cross-sectional analysis of prescribing data shows that an overuse of short-acting bronchodilators is common in young adults. Asthma in adolescence, the period between the onset of puberty and attaining an independent responsible role in society, 13 has received considerable attention, see, for example, Shah 14 and Gabe, 15 but little work has focused on young adulthood.
Despite the repeated documentation of bronchodilator overuse in observational studies across continents and over several decades, 3—10 little is understood about why people, and young adults in particular, overuse their bronchodilator inhalers. We therefore sought, using qualitative methods, to examine the experiences of young adults who overused short-acting bronchodilator inhalers.
We aimed to gain insight into reasons for their overuse. The study was set in a large urban general practice in the UK. We used purposive sampling to obtain an extreme case sample of patients using high and low amounts of short-acting bronchodilators. We identified patients at step 2 ie, co-prescribed inhaled steroids or above of the British Asthma Guidelines.
We wrote to potential participants giving details of the study and inviting them to take part. We aimed to broadly match the high users and low users as far as possible with respect to a range of variables including: age, gender, BTS treatment step, duration of asthma diagnosis, smoking status and visits to accident and emergency departments and hospitalisations for asthma.
We reviewed the sample as the study progressed to monitor and control the evolving composition of the groups. Patients who responded to our written invitation to the study were invited to meet with the researcher SC to obtain full details and to give written informed consent.
The sponsor and funder had no influence on the design, analysis or writing. SC carried out semistructured depth interviews with 21 informants. We developed a topic guide on the basis of the existing literature and our experience in qualitative research in asthma. This was refined during the first few interviews and covered areas including:. Attitudes to medication and views on the role and use of medication, particularly inhaled therapy;.
Field notes were taken, and the researcher recorded general observations of each respondent's attitude and behaviour.
We used the Framework approach to analyse data. The thematic analysis was developed by two of the authors SC and CG who jointly coded all transcripts and resolved differences of interpretation as the analysis progressed. As a validity check, a third author CS, a medical sociologist independently read transcripts and identified no additional themes. The six themes that emerged from the data covering all 21 respondents comprised: impact of asthma, coping, stigma, explanatory models, rationalisation of inhaler use and costs.
We created charts for each theme, cross-tabulating coded text for each against respondents. Table 1 describes the sample interviewed. Most of the respondents were leading lives fairly typical of this age group; some were studying, others were in early careers, or they had young families or responsibilities for ill parents.
Asthma had a major impact on the lives of most respondents. They described how asthma had restricted their childhood and disrupted the course of their lives box 1. Examples included having to change schools, and altering employment opportunities, sometimes dashing hopes of a chosen career. It actually changed my life completely…Because I wanted to be a marine biologist and I actually wanted to study sharks, a PhD in sharks, had my name down at University and all the rest of it and I was diving and I spent many years just having to be a snorkeller because I couldn't use the tanks and stuff like that and any asthmatic who dives now, you cannot take your medication for so many hours before you dive and umm I couldn't be in that situation.
If you can't dive, you can't do your job and actually, because it was all I'd ever aspired to. Interviewer : So what did you do instead? Patient: Nothing as far as I'm concerned laughter. I just became…I did office work and umm that was basically it. I did computer work and very uneventful but then I've got my kids…30f High user. I would have gone into the army if I had of not had it.
I'd have loved to have joined the army. Really would have done and there's lots of things I'd like to have done. I'd like to have been a policeman…policewoman I should say. I'm not saying that I may not have been able to get in, but at the back of my mind I think it's not worth it.
I've got asthma, I can't. My mother stayed with me for a year when I was in Great Ormond Street and my brother and my father stayed in…I lived in a place called xxx which is quite a distance from London, so yeah it did cause a separation in the family.
I remember going to them schools in the hospital. Asthma had implications for the social and personal lives of these young adults. Like wearing tight clothes and stuff. I've got some nice, pretty tops for going out clubbing and stuff and you can't…I couldn't wear tight clothing at all umm and some bras that you wear, you can't wear them either because it restrains your chest almost so you…it tightens up your breathing. Asthma attacks were frightening, life-threatening experiences box 3.
That's the biggest thing is not to panic but it's like…I've always described it as it's like drowning but you're drowning in air because you can't get it.
It's like being six foot underneath the water and you know air is up there and you can't get it. I was out playing once and I started to get really, really tight chested umm and it got really bad and I think I started to panic as well, which made it worse, and it got to the point where I was really, really struggling for breath umm and I probably…bad thing to do umm over used my inhaler just to clear it, which it did, I think it was about ten to fifteen minutes and it was very, very, very scary.
An adverse impact of asthma was more often reported by high users of short-acting bronchodilators. Other frustrations were the failure to find a cure, and the stigmatisation that they felt boxes 4 and 5.
Here we go, is it twenty-two…yeah twenty-two years later, no not really much closer than what they were when I first [was diagnosed] I just wish they'd find a cure…I wish to God that they would. Interviewer: Are you frightened by having asthma?
Respondent: I'm angry with having asthma. Do you feel angry about having asthma? I think, why me? I must admit, yes. I have a 6ft 2 brother who's in perfect health; there's nothing ever been wrong with him and you think, why me? I did go on a sort of like a rebellious point and I didn't want my medicine. It's not worth getting angry over. I'm not really that sort of constitution if you see what I mean—I'm a bit laid back.
I don't really get angry to be honest. You do get penalized for a lot of things I think if you've got asthma. I used to love running, used to love running in the metres and cross-country and all that and, you know, I might have pursued that a bit further had I thought that I wouldn't keep getting jeopardised by having this every so often.
I suppose I feel a bit angry with being dealt with it when what I always wanted to do was farming and it has restricted me from doing it. Well, as a child, it stops you doing quite a lot of things, it limits you umm maybe sets you apart from everyone else a little bit actually if you're quite honest about it inaudible as a child with asthma.
By contrast, despite similar experiences of asthma, low users did not express anger about their illness, describing it as something that was accepted and part of their lives box 6. Sometimes, this normalisation reflected the influence of other family members with asthma. Parental attitudes may have been important, with low users reporting positive attitudes of parents to their illness, and high users reporting negative responses.
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Hancox, R. Bronchodilator tolerance and rebound bronchoconstriction during regular inhaled beta-agonist treatment. Wong, M. Reddel, H. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study.
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Inhaled corticosteroids: impact on asthma morbidity and mortality. Download references. You can also search for this author in PubMed Google Scholar. All authors had intellectual input into the concepts explored, critically reviewed each draft of the full manuscript, and approved the final version. Correspondence to Hao-Chien Wang. The remaining authors declare no competing interests. Reprints and Permissions. Wang, CY. Care Respir. Download citation. Received : 22 July Accepted : 17 February Published : 20 April Anyone you share the following link with will be able to read this content:.
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Advanced search. Skip to main content Thank you for visiting nature. Download PDF. Subjects Asthma. Introduction Asthma is a chronic inflammatory airway disease which affects about million people worldwide 1. Results Baseline characteristics of asthma patients Overall, a total of , patients were included in this study Table 1. Full size table. Full size image. Table 5 Demographic and clinical characteristics of the propensity score-matched population.
Table 6 Association between baseline short-acting beta-agonist SABA use and risk of all-cause mortality and severe exacerbations. Discussion This nationwide study in Taiwan, was the first Asthma surveillance study carried out in Asia and it had several significant findings.
Methods Data source Asthma is a common chronic disease for which patients require regular medical treatment and medication. Study population and SABA or other asthma-related medication exposure The study population comprised patients aged 12 to years old who were enrolled in the Taiwan P4P asthma program between and Statistical analysis Descriptive statistics mean, standard deviation, frequency and percentage were used to characterize the study population at baseline.
Ethics statement All information from patient files was retrospectively and anonymously collected from medical reports, so no written informed consent was collected. Reporting summary Further information on research design is available in the Nature Research Reporting Summary linked to this article.
Data availability The data that support the findings of this study are available on request from the corresponding author. Code availability Available upon request.
References 1. Article Google Scholar 3. Google Scholar 4. Google Scholar 6. Article Google Scholar 7. Google Scholar Article Google Scholar Acknowledgements This study was supported by AstraZeneca Taiwan.
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