Modifiable barriers to adherence to inhaled steroids among adults with asthma: it's not just black and white.
BACKGROUND
Sociobehavioral factors influence adherence to inhaled corticosteroid (ICS) in adults with asthma and warrant exploration as explanations of apparent racial disparities in adherence.


OBJECTIVE
The purposes of this study were to identify barriers to adherence, potentially modifiable by healthcare providers, in a group of African Americans and non-African Americans and to test modifiable barriers as explanations of racial-ethnic differences in adherence.


METHODS
We conducted a cohort study of 85 adults (mean age, 47 +/- 15 years; 61 [72%] female; 55 [65%] African American) with moderate or severe persistent asthma to determine modifiable sociobehavioral predictors of adherence. These were knowledge of the function of ICS, patient-perceived adequacy of communication with the provider, social support, attitude (perception of risks/benefits of ICS), depression, and self-efficacy. Adherence was calculated from electronic monitoring data as the mean of the number of doses recorded per 12 hours divided by the number prescribed, truncated at 100%. Past adherence, baseline severity of symptoms, and sociodemographics were treated as fixed confounders in ordinal logistic modeling.


RESULTS
Adherence was 60% +/- 30%. In bivariate analyses, favorable attitude to ICS (P =.01) was associated with better adherence. Of immutable predictors, African American race-ethnicity (P =.001), lower educational achievement (P =.01), lower household income (P =.002), and more baseline symptoms (P =.003) were associated with poorer adherence. In multivariable analysis, controlling for immutable predictors, favorable attitude was associated with adherence. Favorable attitude was associated with greater adherence in African Americans and non-African Americans. Controlling for immutable factors, the race-adherence relationship was not mediated by the mutable factors, but economic factors (income and insurance) were mediators.


CONCLUSIONS
Attitude is strongly related to adherence but does not mediate the effect of race-ethnicity.
Apter
Andrea J
AJ
Division of Pulmonary, Allergy Critical Care Medicine, Department of Medicine, University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA 19104, USA.
Boston
Ray C
RC
George
Maureen
M
Norfleet
A Lorraine
AL
Tenhave
Thomas
T
Coyne
James C
JC
Birck
Kathleen
K
Reisine
Susan T
ST
Cucchiara
Andrew J
AJ
Feldman
Harold I
HI
D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use*; D000328:Adult; D001741:Black or African American / Q000523:psychology; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy* / Q000208:ethnology*; D001294:Attitude to Health; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D010349:Patient Compliance / Q000208:ethnology*; D012923:Social Class; D014481:United States; D044465:White People / Q000523:psychology
D000305:Adrenal Cortex Hormones