title: Modifiable barriers to adherence to inhaled steroids among adults with asthma: it's not just black and white.
abstract: 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.
authors.affiliation: Division of Pulmonary, Allergy Critical Care Medicine, Department of Medicine, University of Pennsylvania, 3600 Spruce Street, Philadelphia, PA 19104, USA.
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Apter
authors.forename: Ray C
authors.initials: RC
authors.lastname: Boston
authors.forename: Maureen
authors.initials: M
authors.lastname: George
authors.forename: A Lorraine
authors.initials: AL
authors.lastname: Norfleet
authors.forename: Thomas
authors.initials: T
authors.lastname: Tenhave
authors.forename: James C
authors.initials: JC
authors.lastname: Coyne
authors.forename: Kathleen
authors.initials: K
authors.lastname: Birck
authors.forename: Susan T
authors.initials: ST
authors.lastname: Reisine
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Cucchiara
authors.forename: Harold I
authors.initials: HI
authors.lastname: Feldman
mesh_terms: 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
chemical_list: D000305:Adrenal Cortex Hormones