Patterns of concordance and non-concordance with clinician recommendations and parents’ explanatory models in children with asthma

https://doi.org/10.1016/j.pec.2007.11.007Get rights and content

Abstract

Objective

Many children with asthma do not take medications as prescribed. We studied parents of children with asthma to define patterns of non-concordance between families’ use of asthma controller medications and clinicians’ recommendations, examine parents’ explanatory models (EMs) of asthma, and describe relationships between patterns of non-concordance and EM.

Methods

Qualitative study using semi-structured interviews with parents of children with persistent asthma. Grounded theory analysis identified recurrent themes and relationships between reported medication use, EMs, and other factors.

Results

Twelve of the 37 parents reported non-concordance with providers’ recommendations. Three types of non-concordance were identified: unintentional—parents believed they were following recommendations; unplanned—parents reported intending to give controller medications but could not; and intentional—parents stated giving medication was the wrong course of action. Analysis revealed two EMs of asthma: chronic—parents believed their child always has asthma; and intermittent—parents believed asthma was a problem their child sometimes developed.

Conclusions

Concordance or non-concordance with recommended use of medications were related to EM's and family context and took on three different patterns associated with medication underuse.

Practice Implications

Efforts to reduce medication underuse in children with asthma may be optimized by identifying different types of non-concordance and tailoring interventions accordingly.

Introduction

Although strong evidence shows that daily controller medications prevent adverse outcomes and improve functional status in children with asthma [1], [2], many children do not use them daily as recommended [3], [4], [5], [6], [7], [8]. Studies of children with asthma have commonly found rates of adherence with medication regimens of 50% or worse [9], [10]. Lower levels of asthma knowledge, family dysfunction, limited access to medications, low treatment expectations, and negative attitudes toward inhaled controller medications have been associated with poor adherence [11], [12], [13], [14], [15]. Yet effective interventions to improve adherence remain elusive. A more thorough understanding of the patterns of controller medication underuse is needed to help clinicians develop the most effective strategies for addressing this highly complex problem.

Parents’ decisions about managing their children's asthma may be guided by their explanatory models (EMs) of asthma [16]. EMs include perceptions of etiology, time and onset of symptoms, pathophysiology, course of illness (including severity and chronicity), and treatment. EMs integrate personal beliefs, cultural norms, and past experience. Prior work examining parents’ explanatory models of asthma has broadened our understanding of how parents conceptualize asthma. These studies have shown that families rely on their cultural and environmental contexts to understand asthma and have described differences between explanatory models of patients and providers, indicating the need for providers to explore explanatory models with parents in the clinical encounter [17], [18], [19]. However, these studies do not show how EMs relate to decisions about asthma management in the context of daily life.

Our study was designed to understand the relationship between EMs and concordance regarding medication use among children with asthma. We use the concept of concordance [20], [21], departing from “adherence” or “compliance”, the terms typically used when comparing actual behavior against an objective standard (e.g. medication doses taken compared with those prescribed). Concordance reflects the match between provider recommendations and “contrasted but equally cogent” [22] parental beliefs and behaviors regarding giving medications. Many studies on adherence in chronic illness label patients as either ‘adherent’ or ‘non-adherent’ [23]. Whereas a few studies discuss reasons for non-adherence in child asthma, no empirical work to date has explicitly distinguished between types of non-adherence.

Through the use of qualitative interviews, we sought to explore patterns of parents’ reported behaviors regarding giving children medication, and how these behaviors were interconnected with EMs and other features of family life. Our aims were to (1) define and describe patterns of concordance or non-concordance between families’ use of medications and clinicians’ recommendations; (2) examine parents’ EMs of asthma; and (3) describe patterns amongst concordance or non-concordance, EMs and other contextual factors.

Section snippets

Participants and recruitment

Participants were a purposive sample of African-American, Latino and white parents of children aged 5–12 years with persistent asthma. The sampling frame was theoretically driven by (1) previous work [24] indicating differences in adherence among minority children and (2) theoretical work indicating that explanatory models and patient-provider communication may vary culturally [16]. Parents were recruited from three socio-economically and ethnically diverse sites in the Boston area: an

Results

We approached 128 parents; 54 participated in audio-taping of clinical encounters, and 44 of these participated in interviews. Among the non-participants, seven declined to participate, 64 were ineligible based on screening criteria, and three had the consent process interrupted and could not participate. Of the 44 who participated in interviews, seven were excluded from analysis because the child had not been prescribed a controller medication, leaving 37 parent interviews for the current

Discussion

We found that non-concordance with clinician recommendations for asthma controller medications fell into three distinct types: unintentional, unplanned, and intentional. Previous literature on adherence distinguishes between adherence, non-adherence, and occasionally erratic adherence to describe patients who take medications inconsistently. We have identified clear distinctions between three types of non-concordance, based on the ways in which parents described how they give their children

Acknowledgments

We are grateful to Jack Lasche, MD, and the clinicians in the Department of Pediatrics of Harvard Vanguard Medical Associates in West Roxbury; and Pauline Sheehan, MD, and the clinicians in the pediatric outpatient clinic at Boston Medical Center, for their support and encouragement. We appreciate the excellent work of our research assistants, Aarthi Iyer, Ludmilla Reategui-Sharpe, and Alexandra Meunze. We are indebted to the many parents who contributed their time and perspectives as

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    Supported by a grant from the National Institute of Child Health and Human Development (NICHD) (R01 HD044070). Dr. Lieu's effort was supported in part by a Mid-Career Investigator Award in Patient-Oriented Research from NICHD (K24 HD047667). Dr. Bokhour's effort was supported in part by the Department of Veterans’ Affairs, Health Services Research & Development service. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Dr. Bokhour had full access to all the data in this study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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