Health
Vol.09 No.07(2017), Article ID:77565,18 pages
10.4236/health.2017.97075
Perceived Barriers to Asthma Therapy in Ethno-Cultural Communities: The Role of Culture, Beliefs and Social Support
Michele Shum1
1University of John Hopkins, School of Public Health, Baltimore, MD, USA
2University of British Columbia (UBC), Faculty of Medicine, Research Scientist at the Centre for Clinical Epidemiology and Evaluation, UBC, British Columbia, Canada
3British Columbia Cancer Agency, Smoking Cessation Project, Vancouver, Canada
4Institute for Heart and Lung Health, The Lung Centre, 7th Floor Gordon and Leslie Diamond Health Care Centre, UBC, British Columbia, Canada
Copyright © 2017 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
Received: February 9, 2017; Accepted: July 9, 2017; Published: July 12, 2017
ABSTRACT
Background: Adherence to therapy is integral to successfully managing asthma, which requires comprehension of what, when, and how to use medication and diligence in following management plan. Asthma patients from ethnic minority groups have more morbidity and reported filling their prescriptions less often. Limited information is available in Canadian literature on ethnic differences in their perceptions of asthma management. We aimed to document patient perceived adherence to asthma therapy among targeted ethno-cultural groups. Methods: We evaluated perceived barriers to therapy adherence, including: cultural beliefs and practices, patient/care-provider communication, self-management knowledge, and medication costs. We conducted a cross sectional study and interviewed 85 Chinese or Punjabi- speaking adult asthma patients. Results: Lack of sufficient instructions from physicians, language/communication barriers, lack of skills on how to use inhalers, and high medication costs and medication side effects were most reported barriers to proper self-management practices. Most participants lived with others in the same household and reported high social support from home caregivers. The influence of family on self-management practices was obvious. Conclusion: Better understanding of patient needs, provision of culturally and linguistically appropriate education, and inclusion of home caregivers into the management practices are necessary to improve asthma outcomes in Chinese and Punjabi communities.
Keywords:
Asthma, Medication, Family Involvement, Caregiver, Language, Culture, Educational Materials, Knowledge, Communication, Cost, Beliefs
1. Introduction
In Canada, asthma affects about 2.2 million adults and 0.8 million children (12 percent of Canadian population), and is highly prevalent in the mainstream population; in particular it tends to be less well controlled among individuals of lower socioeconomic status and low income families. Asthma is also prevalent in the Canadian recent immigrant communities and constitutes a disproportionate burden of disease compared to Canadian-born individuals. Asthma affects ethnic communities differently in terms of disease-related outcomes including morbidity, and mortality, when compared with the mainstream community [1] . Among these populations are Mandarin, Cantonese, and Punjabi speaking immigrants who are one of the largest and fastest growing cultural communities in Canada [2] . Within British Columbia, the Greater Vancouver Area (GVA) is the main location for these ethnic groups [3] . According to the 2010 Canadian Census data, these ethno-cultural communities make up 45% of GVA’s immigrant population [4] .
Studies reveal that well controlled asthma requires adherence to therapy including self-management, proper use of medications, and following provider’s instruction on treatment regimens [5] [6] [7] [8] [9] . However, less than 50% of asthma patients adhere to medication recommended by their care providers [7] [10] . Poor adherence is especially prevalent in less educated and disadvantaged groups [11] [12] [13] . Non-adherence has many implications, including preventable disease progression, increased risk of exacerbations, reduced functional ability and quality of life, and an increased risk of death [14] [15] [16] [17] [18] . In contrast, adherence to therapy is associated with reduced mortality and a better quality of life [5] [6] [19] [20] [21] [22] .
Previous qualitative research identified multiple factors that can affect ethno- cultural patients’ ability to learn and adhere to care plans and follow caregivers’ prescribed therapy regimens, including patients’ perception of their disease, type of treatment or medication, quality of patient-provider communication, costs of medications and treatment procedures, and obstacles to comprehension and uptake posed by language and cultural barriers [7] [9] [12] [23] [24] [25] [26] . Patients from ethno-cultural communities may face barriers to health care parity due to socio-cultural
Similar underlying determinants of proper self-management practices reported by different studies in mainstream and ethnic minority groups. While there are obvious gaps noted in both groups, including patient/care-provider communication, self-management knowledge, and medication costs, there is a knowledge gap in our understanding of how cultural beliefs and practices may effect therapy adherence among some ethno-cultural groups [28] . Through a cross-sectional study we investigated the link of these variables with self-re- ported adherence to asthma therapy and simultaneously examined the feasibility of involving family members, in the learning and self-management process. From our previous studies [29] [30] [31] [32] , we observed that family members who normally give care to the patient (hereafter termed the “caregiver”) are a key health-related social support for many patients in ethnic communities. The purpose of this paper is to summarize our findings in terms of identifying: 1) the issues and concerns re adherence to asthma therapy in Cantonese
2. Methods
A participatory approach was applied to conduct the study and collect qualitative data from asthma patients in the target communities. This study was part of a larger intervention project aimed to develop and validate educational materials related to asthma management in Chinese and Punjabi communities [31] . The main objective of this study was to identify patients’ perceived barriers to engage actively in the management of their asthma
2.1. Participant Recruitment
A purposive sampling method was applied to enrol asthma patients who had physician diagnosed asthma
2.2. Measurement Tool Development
Given the absence of a validated assessment tool in the target languages related to the objectives of this study
2.3. Data Collection
Data was collected during in-person interviews and the assessment tool
2.4. Data Analyses
To analyze the data
3. Results
3.1. Participants’ Characteristics and Medication Use
42 Chinese and 43 Punjabi patients completed the study (aged 21 to 87 (Mean: 62.9 years
3.2. Asthma Knowledge, Understanding, and Beliefs
Participants’ perspectives, knowledge, and beliefs about asthma medications, origin of their disease, and issues related to medication costs are summarized in Table 2. In general, the majority of the participants in both ethnic groups had difficulty understanding the reason for using reliever vs. controller medications and many of them blamed their doctor for their misinterpretation and indicated they never received instructions or an action plan in their language on how to correctly use inhalers and the reasons for using different medications. A suggestion made by some participants was a need to develop educational handouts and videos to be provided by an asthma educator or doctor from their community. They felt the focus of such discussions should include: medication differences, potential side effects of medications, correct use of inhalers. They also emphasized the need for educational materials that could be taken home.
Additional concerns included a belief that medication would be ineffective or cause an addiction. High cost of medication in
3.3. Patient Perceived Trust of Care Provider
When asked whether they would adhere to a physician’s instructions on how
Table 1. Characteristics of the patients: patients who completed the interventions (n = 85).
Table 2. Participants’ perspectives and concerns about origin of diseases, asthma management, new medication development, and patient education.
they should use their asthma therapy
3.4. Perceived Barriers to Asthma Therapy
Language and cultural barriers
3.5. Link between Cultural Beliefs and Practices and Asthma Therapy
There were some similarities and differences between the Chinese and Punjabi groups in their perceptions of the origins and implications of having asthma and self-management practices. For instance
Table 3. Patients’ concerns and comments about their challenges related to their asthma management.
to involve in self-care of their chronic illness.
4. Discussion
This study examined the issues and concerns of asthma management in Cantonese
Although we focused on overlapping themes that emerged within the studied ethno-cultural groups
Another challenge was communication barriers between patients and providers. Many participants spoke of their perceptions in regards to how doctors do not respect their culture
The last but not least challenge identified by participants considered to be a barrier to therapy adherence was the cost of medications prescribed by providers. Different studies have shown involvement in the care process and trust between patient and care provider are strongly correlated to a willingness to pay for medications [9] [24] . As the Canadian health care system does not provide universal insurance coverage for medications, cost is a significant factor for most patients in both mainstream and ethnic minority communities and it reduces people’s capacity to achieve consistent adherence [18] [20] [21] . The total costs for asthma treatment in Canada are likely much higher than many other developed countries [5] [21] . A recent study has shown that around 64% of asthma patients in British Columbia (BC) had poorly controlled asthma and this group was responsible for 90% of the overall cost of asthma care in BC [42] . This financial burden was significant among participants of our study as more than 55% of study subject were over 65 years old and over 60% were unemployed or retired and relying on social insurance. Most of these participants indicated that high cost of asthma medication was a barrier to regular use of medication and suggested the possibility of reimbursement of costs by the government for low-income families [43] . In our study, we found that Punjabi patients were more concerned about the cost of the medications, while Chinese patients focused on the side effects of prescribed medications. Under dosing of medication was common
Although the literature of the family’s role in supporting individuals with chronic disease, including asthma, is inconclusive about the effectiveness of family-oriented disease self-management interventions, we identified asthma management in Chinese Mandarin and Cantonese communities is a collective decision made by the patient and family members. For instance, a major influence of family member on self-management and medication adherence was facilitating the accessing and using asthma services as well as use or decline using medication, as prescribed. At various times throughout the study
5. Limitations
There are some limitations in our study. First
6. Conclusion
Social context
Our findings show the usefulness of involving patient and caregiver in the learning process and engaging in self-management practices while providing culturally and linguistically appropriate information. Such practice can empower patient to develop and strengthen a sense of self-efficacy and confidence in managing their asthma. Patient education is the major intervention to promote self-management practices. However
Practical implication: Our study has shown that to improve asthma self- management and therapy adherence, a provision of educational intervention to improve disease-related knowledge should be complemented with behavioral modification and empowerment techniques to enhance patients’ self-efficacy skills. To be successful, asthma self-management in ethnic communities, in particular Mandarin and Cantonese groups, does require a multifaceted approach that incorporates patients’ and family caregivers’ opinion and perspectives in designing and implementing strategies to empower patients to become informed individuals. It is also essential to improve patients’ confidence in their ability to follow physician instruction about medication adherence, as a major predictor of successful disease management practices. A fully informed patient is capable to plan and achieve self-care practice goals. The results of our study indicate that side effect, costs, cultural beliefs and practices, and social influence (such as family-oriented modeling) can be important factor in medication adherence. Therefore, appropriately developed self-management interventions, with direct involvement of patient and family members, can lead to increased patient’s disease management competency overtime. Such interventions should emphasis on three main factors to promote medication adherence in Mandarin and Cantonese communities: improve patient understanding of physician instruction by improving patient-physician proper communication; correct patient’s misconceptions about medication side effects and misperceptions about medication efficacy; and involve family members (as immediate caregivers at home) in disease management practices.
Acknowledgements
The authors would like to thank the community members
Punjabi community video
http://www.youtube.com/watch?v=qto8Sx2VIBM
Punjabi knowledge video
http://www.youtube.com/watch?v=SuS-YDT9vcE
Chinese community video 1
http://www.youtube.com/watch?v=LmT1qunrs1U
Chinese community video 2
http://www.youtube.com/watch?v=UhPkF6RDInU
Chinese knowledge video
http://www.youtube.com/watch?v=BJCOQK9EZ1k
Funding Information
This project was funded by the Canadian Institutes of Health Research (CIHR) and partly from the Institute for Heart and Lung health at The University of British Columbia
Conflict of Interest
The authors have disclosed no conflicts of interest.
Cite this paper
Shum, M., Poureslami, I., Liu, J. and FitzGerald, J.M. (2017) Perceived Barriers to Asthma Therapy in Ethno-Cultural Communities: The Role of Culture, Beliefs and Social Support. Health, 9, 1029-1046. https://doi.org/10.4236/health.2017.97075
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