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Summer, 2010

Asthma Research into Action

Opening the Flow of Two-Way Communication

Behavior—it’s the linchpin between adherence to taking medication and outcomes.

“All medicine requires patients to be engaged at some level, whether it’s taking a pill or using an inhaler,” said the Director of the Johns Hopkins Center for Adherence Research, Cynthia S. Rand, PhD. “The best drug in the world is useless if not taken.”

Dr. Cynthia Rand
Dr. Cynthia Rand, Johns Hopkins Center for Adherence Research

And, as research has shown, at least one third of people who have asthma are not taking their medication as prescribed. According to Rand, the challenge is recognizing that asthma is both chronic and episodic.

“It is human nature to react when you have an episode, but it’s easy to forget about it afterward and lapse into mistakenly thinking ‘Oh, my asthma has gone away,’” said Rand.

Rand is an internationally known expert on medication adherence and directs both the Johns Hopkins Center for Adherence Research and the National Institutes of Health (NIH)-sponsored Howard-Hopkins Center for Reducing Asthma Disparities. She is also the principal investigator of two asthma-related NIH projects.

Experience has shown her the “heart and soul” of getting patients to stick to their therapy is open, non-judgmental, two-way communication between the health care provider and patient. Bridging the communication gap, however, requires clinicians to do more than active listening. It requires them to ask themselves three critical questions:

  • Does the patient have the knowledge to adhere to his or her therapy?
  • Do s/he have the motivation to do so?
  • Is s/he able to do so?

These questions stem from three types of non-adherence behaviors:

  • Unwitting: A patient is willing to take medication and follow a regimen but has misunderstood how to do it, often due to low health literacy.
  • Erratic: A patient is motivated but factors such as cost or forgetfulness prevent him or her from sticking to the therapy
  • Intentional: A patient deliberately avoids taking medication because of certain concerns or convictions. For example, a patient may believe that the medication is addictive, that the dosage is too high, or that he or she no longer has asthma.

Rand notes that there is often overlap among these categories, especially within families, and recalls a particular interview with the mother of a patient from a low-income, inner-city neighborhood.

“She told me that her son’s asthma had gone away. I asked if he still had a cough. She responded, ‘He just has that normal childhood cough,’” said Rand. “She [the mother] had redefined what it meant to have asthma, despite the fact that her son was still coughing on the playground and it was also waking him up at night.”

To Rand, the interview illustrated the importance of recognizing the role of underlying health beliefs and crafting multi-faceted strategies to address these beliefs and other psychosocial factors. She identifies three strategies that clinicians can use to get patients (and families) back on track:

  1. Tell Me Back: Ask patients to repeat back to you their understanding of the therapy and how they are supposed to use it. Use this strategy during every interaction with the patient.
  2. Enhancing motivation: Ask patients to identify personal asthma goals, and then talk to them about how sticking to their therapy will help them reach those goals.
  3. Behavioral Strategy: Create a system of monitoring, and then provide rewards for adherence. Explain that following their therapy will help prevent problems with their asthma and allow them to live a fuller life.

“There are no silver bullets, but our strategies can help families identify their personal goals and then directly link to how using that therapy can help them reach those goals,” said Rand.

By reaching those goals, they have the potential to live fuller, more productive lives, to the benefit of us all.

Last Updated February 2011

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