Literature Review: Asthma Adherence in Adolescence

Literature Review: Asthma Adherence in Adolescence

Asthma is a common health condition amid the United States adolescents. Roughly 11.2 percent of American adolescents have asthma. The increased mortality rates and risk of mobility can be ascribed to suboptimal self-management (Mammen et al. 2018).  Throughout the adolescents’ stage, a person may face tough transitioning moments, and this is because they experience emotional, physical, and hormonal changes that create turmoil alongside a condition that needs proper management.  Moreover, this is the time, responsibilities partnered with this condition are transferred gradually from parents to young adult.  The transitioning process and development of their independence may conflict with their beliefs and actions for proper asthma self-management. In adolescents, self-management has been hypothesized as the behavior to monitor, communicate, manage and prevent symptoms of asthma and to control the outcomes.

The decrease in the supervision of parents in most cases come prematurely as most of them are ill-equipped to handle self-care. This is because most adolescents depend on parents for support and guidance, to assist in avoiding triggers, help in refiling medication and accessing healthcare. Several previous research on the topic hold that there is poor self-management of asthma among adolescent due to limited engagement and techniques, furthermore, their communication to healthcare professionals (HCP) about their conditions is inefficient. This explains the poor adherence adolescents have towards asthma treatments and control measures. Recently, there has been an increased concern on the importance of self-management of asthma among teens. Moreover, several existing systematic reviews focus on adolescents’ awareness of self-management and education. Several recent systematic pieces of research have outlined the barriers and facilitators leading to effective adherence among asthmatic teenagers. The papers universally identify some overwhelming themes like the partnership between HCP and the adolescent, issues around education and medication. In general, this period in life may be expected to have its own particular influence, given that the adolescent is already undergoing associated challenges like gaining autonomy. Therefore, asthma adherence during this period might be expected to come along with some particular influences. Most clinical reviews have focused on either child or adult asthma and only few on adolescent’s behavior. This review specifically focuses on the latter group of adolescent behavior. As a result, this paper will generally focus on a systematic review of facilitators and barriers to conceptualized behaviors that are associated with poor adherence in adolescents with asthma.

Literature Review

Epidemiology of Health Problem in Population

In the U.S. asthma has become the leading threatening health condition among young children and adolescents. The most recent Center for Disease Control (CDC) statistics on the burden of asthma among different age groups indicate the disease is most prevalent among children and adolescents from birth to 18 years old. The estimated current asthma incidences are projected to be about 8.3%. The asthmatic individuals from 5-14 years are valued at 10.1% and those of 15-19 years are approximately 10%, this shows the highest percentage compared to other demographics. The general overview statistic insight of CDC shows that young teens and adolescents have the highest prevalence of 11.2% and 10.1% respectively. The disease is most common among the adolescent for wide-ranging reasons. For instance, most of them tend towards trigger avoidance, non-adherence with medication, and other risky behaviors like marijuana or tobacco smoking alongside the use of cocaine. Likewise, many of them nursing asthma have higher risks of other serious complications due to denial and under-appreciation of the condition severity. Asthma has become prevalent among adolescents and is considered a life-threatening factor within this age group as they have difficulty adhering to the medication plan. The victims in this age group normally do not appreciate the risk of poorly controlled asthma. Most adolescents end up developing a chronic illness in the process of striving to reach adulthood since they view the treatment and management approaches as interfering with their emerging independence.

National Statistics: The most recent state and national statistics on the burden of asthma in the United States show that the disease is most prevalent among certain gender, age and ethnic groups. The data used in this paper were administered by CDC from the national and state surveillance system. The data show that the current asthma prevalence is 7.8% across the population with 8.4 % likelihood in children of age less than 18 years. The adults of age 18 and above were reported to have 7.6 % prevalence. Across all age groups, the disease is more common among the people of age 15-19 years with a 10.2 % popularity. Moreover, the disease is mostly dominant among the females which is currently at 9.1%, with girls below the age of 18 years at 6.9% incidence and women above 18 years around 9.7%.  The Asthmatic males were estimated to be around 6.5%; the boys below the age of 18 years appraised at 9.9% and older men about 5.4%.

Currently, there is a significant ethnic and racial disparity in the asthma prevalence distribution. According to the CDC, (2015) report, more blacks and whites were reported to be suffering from lifetime asthma than the Hispanics and other ethnic groups. According to the CDC statistics, on race and ethnicity, whites with asthma were reported to be approximately 7.8%, those below 18 years being 7.4% and above 18 years 7.9%. The disease prevalence in black is presently at10.3% with 18 years and below at 13.4% and above 18 years old at 9.1%. The asthmatic Hispanics group are around 6.6% with 8.0% of 18 years and bellow and 5.9% in adults above 18 years (CDC, 2015). Asthmatic Puerto Ricans are roughly 13.9% and American Mexican around 6%. Another research conducted to examine the prevalence of asthma among adolescents led that the disease exacerbation among the American high school students is rampant. Data analyzed from a survey by the national Youth risk behavior indicated that about 18.9% of students in high school had a doctor’s report of positive asthma diagnosis, and 16.1% had current asthma. 37.9% of the people with current asthma had experienced a recent episode of an asthma attack. The research also holds that more adolescents’ ladies around 44.5% were reported to suffer from asthma than the teenage boys (31.1%).

Healthy People 2020: Almost 4,000 Americans die from asthma every year. Kosse et al. (2017), speculates that adolescents and young adults make up to around 22% of the US population dying with asthma every year.  The general goal of Healthy People 2020 is to enhance healthy development among this age group by improving their safety, health, and well-being. Although asthma is incurable, it may be managed and controlled properly for a longer period. By avoiding contact with environmental triggers and following a medical management plan those who have asthma can live a productive life. A report by CDC states that about 23 million people in the US are affected by asthma yearly and nearly $21 billions of national expenditure goes to asthma alone. The goals of healthy people 2020 is to reduce the deaths rates, visits to emergency departments, missed school and work, activity limitations and hospitalization. Nevertheless, they aim to increase the number of people living with asthma receiving appropriate care and surveillance at the state level. The 2020 goals regarding asthma-related death include reduction of deaths rates from 6-11 death in every millions of people aged 65 and above. Regarding annual asthma-related hospitalization, the goal is to reduce it from 41.4 to 18.1 in every 10,000 children under the age of 5 years.  For people of age 5-64, the aim is to decrease mortality rate from 11.1 to 8.6 per 10,000. Another specific goal is to generally reduce the percentage rate of adolescents and young adults with COPD

Risk and Protective Factors

People with asthma normally face a number of risk factors: some of which include the use of tobacco, environmental hazards, sedentary lifestyle and obesity. Ghanname, et.al (2018), in his research hold that half of the patient who were overweight or obese seemed to have less influence on asthma control. The overweight people showed a multiplied asthma risk than the less overweight patients. Another risk factor is the active smoking which can be the onset cause of several chronic obstructive pulmonary diseases (COPDs) or may as well reduce their control efficiency. In addition, smoking alters the response to inhaled corticosteroids. Non-compliant patients and the untreated patient is another risk factor for asthma control, a condition believed that if it is well observed, rhinitis improves its control. A research by Holley, et.al (2017) found that about 9.6% of patients with GERD reflux showed high risk factor on asthma. The research also indicated that contaminated respiratory diseases or animal allergy are some other factors. According to his research respiratory infection may cause 5.7% times more risk in patients with asthma. Patients who are allergic to animals have 2.8 times more risk and those with contagious diseases also showed about 3.4 times more risk.

Some of the protective factors identified for uncontrolled asthma include adherence to asthma treatments, having two or more children and having health insurance (Ghanname, et.al 2018). The odds of being controlled by asthma patients significantly increased on those patients who observed the treatment by 7%. In regard to health insurance, those patients with health insurance showed a significant asthma control, with 40% odds to have controlled asthma effectively. Lastly, those patients with more than 2 children were likely to control asthma at a rate of about 50 % more compared with those having less children.

Consequences

When one person in a family has asthma, not only is the person affected but so is the whole family. The stress of living with a chronic disease come out in varied ways for the community, family, and individual. Individually, the patient may be frustrated with their condition and all the work that come with it in terms of management and adhering to modification. Socially, asthmatic individuals may tend to get involve in fights, be stubborn, less likely to cooperate, withdrawn as well as be very anxious. The aggression may be due to the emotional instability one undergoes during adolescents or other asthma related stress. On the other hand, those parents with a child having asthma are likely to suffer from headache, fatigue, insomnia, loss of appetite and depression (Blackman 2014). The siblings of the individual may feel guilty for not assisting, embarrassed of the symptoms the sibling is experiencing, afraid of contracting the disease, or jealous due to extra attention their fellow is getting. The financial strain that come with chronic illness is another factor that cannot be overlooked.  The family may be forced to live below their means to cover for the child’s medication. Out of pocket expenses may drain a family financially even with the health insurance coverage. A financial toll can cause a high emotional strain on the family just as it may cause an individual and the society. Nationally, asthma places a significant financial burden to the society. In the US asthma medical cost has augmented by $3,266 annually from 2015. Concurrently, the medical cost of asthma patients has steadily increased for some individuals; for instance, the uninsured person with around $21,145 and for those living below poverty level it amplified by $3,581. Thus, asthma was responsible for about $3 billion lost between the years 2008-2015 due to missed school days and works (McMurray, 2017). In general, the US Statistics estimates a pooled sample that amounted to around $82 billion as lost in asthma related health consequences yearly.

Implications for Practice

The extent to which a person’s behavior and action matches the agreed clinician recommendations is known as adherence (Tseng, Chang, & Wu, 2017).  It is a dynamic and continuous process that is influenced by several factors, including the treatments, the disease, patients related factors, socio-economic factors, the system as well as the healthcare team. The clinicians’ outcome may be affected adversely by non-adherence and lead to an amplified cost of healthcare. For people with long term conditions like asthma, the rate of adherence is about 50 % and 30% among adolescents age between 10-19 years. Most adolescents with asthma normally find adherence to a challenge since it requires cumbersome regimens including daily multiple medications and therapies.

According to Engelkes (2015), some of the factors that affects adolescents’ adherence to the medical regime may yield contradictory results if well managed.  Some of the aspects that seem to have positive effects on adherence include, close friends, functioning family, control of internal focus, the beliefs that the parent has on the efficacy of treatment and seriousness of the illness, treatment with instantaneous benefits, and the empathy of the physician. However, there are other factors with negative effects on adherence which include mental health issues with the care provider, being an older adolescent, complex therapy, conflict in the family denial of illness and medication with side effects. Therefore, adolescents experiencing social, family, emotional or mental health issues may struggle more with adhering to the medical regime. During the teen years, low investment to treatment plans may be a sign of other psychosocial problems or depression. The attitudes and beliefs of a patient are some of the most studied determinants of adherence. Many personal variables that are associated with adherence have been identified by other tools like the Health Belief Model. Moreover, several systematic researches have been conducted on asthmatic adolescents’ medical regime adherence to asthma

An article by Blaakman et.al (2014), on teen’s asthma medication adherence, was led on how teens normally undertake their daily medical regime. The main purpose of the study being understanding teens experiences with management of asthma, participation is school based interventions and preventive medication adherence. A pilot study that included motivational interviewing and observed medication therapy at school was conducted. The study involved teens of the age between 12-15 with persistent asthma and with preventive prescribed medication. At the final survey, a semi structured interviews occurred. To identify themes, data coding was enabled using a qualitative content analysis. In the study results, arguments were grouped as program-specific or general asthma management. Generally, health management teens found routine cumbrous as they are always hurrying to catch up with something hence interfering with the medication. The other issues linked to medical non-adherence was forgetfulness. Some of the barriers acknowledged for proper medication use identified include, social priorities and competing demand related preparing for school. A concern brought up by the adolescents was that independence with asthma medications had a lot of benefits to them like feeling more mature and responsible as well as avoiding parental nagging. The teens also reported varied program-specific experience with the caregivers. 50% of the asthma victim teens who participated reported having a positive rapport with their school nurse, while some of them had a feeling that the nurse was dismissive. Some of the unexpected barriers identified and benefits with the school facility included the distance to the nurse clinic, perception about leaving the classroom and the necessity of other school routines. The study concluded that teens with asthma normally benefit from preventive medications adherence. However, they encounter various challenges to proper use. Teens need support from people around them to improve medication adherence.

A research by De Simoni et al (2017), explored facilitators and barriers to inhaled asthma treatment among the adolescents.  A qualitative analysis was conducted by holding a forum online for individuals with asthma. 54 forum participants made up of 39 adolescents of the age less than 16, with 5 adolescents’ parents who have children dealing with asthma were sorted using the search terms “adolescents inhaler” and “teenage inhaler”. The results obtainable indicated that poor routine, inadequate techniques with inhaler, forgetfulness, organization difficulty like recurrent prescription and some parents not accepting or understanding that their child had asthma were some of the reason that made it difficult to observe the inhaler routine. The adolescents may benefit from self-monitoring, like using login adherence charts however, parent monitoring and promoting inhaler treatment was more helpful (Robert s,et.al 2018). Factors that were determined to reduce the motivation to adhere to treatment include representation of asthma as episodic rather than a lasting condition requiring confinement to inhaler treatment. Adolescents with asthma expressed some of their concerns attributed to side effects of using inhaler like social stigma and embarrassment. Implementation to adhere included; adolescents should actively seek general consultant or practitioner’s adjustments and learning to deal with stigma and other side effects. Moreover, the study stressed on the responsibility of parents as an instrument in creating adherence and sense of responsibility in adolescents.

Rhee, et.al conducted a research on asthma control and adherence in adolescents. According to the research, most individuals in this age group normally report poor adherence to asthma control and medication. Some of the factors the paper identifies to enhance poor asthma outcomes among adolescent are the cognitive factor associated with this group. These aspects include self-efficacy, barrier perception and outcome expectations. The main objectives of the report were to examine the degree of inter correlation of these cognitive aspects and extent of prescription adherence in urban adolescents. An aggregate population of 373 adolescents of the age range between 12-20 years suffering from asthma completed a questionnaire that measures their self-efficacy to asthma, outcome expectations, and asthma control and medication adherence. To look at the extent of effects of these cognitive aspects to their health the research piloted multiple linear regression. The variables controlled for covariates include age at diagnosis, household income, sex, and current age. On average the participants were 14.68 (+-19) years, with about 50% being females and around 78.8% African American. According to the research self-efficacy projected a better control of asthma, nonetheless, barrier perception showed a poorer disease control. Independently, self- efficacy predicted fewer missed medication doses. Therefore, a multifaceted approach is required in improving treatment adherence among adolescents with asthma. Intervention on adolescents with asthma should focus on addressing potential or actual barriers to treatment adherence and self-efficacy, as this could improve asthma disparities among urban adolescents.

Another survey conducted by Desager, Vermeulen, & Bodart, (2018), to assess the level of treatment adherence in adolescents and children with asthma, indicated that the attitude of the parents and adolescents towards the disease therapy and their expectation of the treatment determined asthma outcome. The study outcome was identified using manual selection and PubMed searches to retrieve past literature. Results from the study show that asthma medication adherence varies across people of all age groups. For children with asthma, most of their parents expressed fear of side effects of inhaling corticosteroids however, there is no clear concern on adherence at this age. Most adolescents with asthma adapt to the use of corticosteroids conferring to asthma symptoms prevalence, nonetheless, in the absence of symptoms, they eliminate or reduce medication adherence. Parents and pediatric asthma patients tend to underestimate the level at which asthma can reduce the quality of their lives either by assuming that there is a better control or by underestimating asthma severity. Therefore, the main cause of poor management in adolescents with asthma and parents according to their study is the concern of suboptimal knowledge and insufficient information on inhaled corticosteroid, a factor which was linked to poor adherence. The conclusion made was that both parents and adolescents should be educated on proper asthma care in order to improve the adherence level among the population. Generally, the major causes of non-adherence among teens were found to be, poor routines, inadequate inhaler usage techniques, forgetfulness and denial from family members as they fail to understand the condition during this period.

Conclusion

In conclusion, the CDC speculates that approximately 11.2 % of American adolescents have asthma. The transitioning process and development of independence usually conflict with their beliefs and actions for proper asthma self-management, hence interfering with medical adherence. Non-medical adherence is one of the main factors that affect adolescents’ self-care. Without proper adherence to medication, asthma can take a toll on someone’s health, hence affecting the person, the people around them as well as society. In the United States, billions of dollars have been lost to asthma related health issues hence affecting the whole healthcare and the nation’s economic priorities. Therefore, a multifaceted approach is required in promoting medical adherence among adolescents with asthma. Moreover, intervention on adolescents with asthma should focus on addressing potential or actual barriers to treatment adherence and self-efficacy, as this could improve asthma disparities among adolescents.

References

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