Chest
Volume 129, Issue 3, March 2006, Pages 573-580
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Original Research: ASTHMA
No Symptoms, No Asthma: The Acute Episodic Disease Belief Is Associated With Poor Self-Management Among Inner-City Adults With Persistent Asthma

https://doi.org/10.1378/chest.129.3.573Get rights and content

Objective

Asthma morbidity and mortality is highest among inner-city populations. Suboptimal beliefs about the chronicity of asthma may perpetuate poor asthma control among inner-city asthmatics. This study sought to characterize beliefs about the chronicity of disease and its correlates in a cohort of inner-city adults with persistent asthma.

Design

Prospective, longitudinal, observational cohort study.

Patients

One hundred ninety-eight adults hospitalized with asthma over a 12-month period at an inner-city teaching hospital.

Measurements

Sociodemographics, clinical history, disease beliefs, and self-management behaviors were collected by interview. Information on self-reported use of inhaled corticosteroids (ICS), peak flowmeters, and regular asthma visits was collected during hospitalization, and 1 month and 6 months after discharge.

Results

This cohort was predominantly low income and nonwhite, with high rates of prior intubation, oral steroid use, and emergency department visits and hospitalizations. Overall, 53% of patients believed they only had asthma when they were having symptoms, what we call the no symptoms, no asthma belief. Men patients, those ≥ 65 years old, and those with no usual place of care had greater odds of having the no symptoms, no asthma belief, and those receiving oral steroids all or most of the time or with symptoms most days had half the odds of having this belief (p < 0.05 for all). The no symptoms, no asthma belief was negatively associated with beliefs about always having asthma, having lung inflammation, or the importance of using ICS, and was positively associated with expecting to be cured. The acute disease belief was associated with one-third lower odds of adherence to ICS when asymptomatic at all three time periods (p < 0.02 for all).

Conclusion

The single question, “Do you think you have asthma all of the time, or only when you are having symptoms?” can efficiently identify patients who do not think about or manage their asthma as a chronic disease.

Section snippets

Study Participants

The cohort study has been described previously.20 We prospectively identified an inception cohort of all adults hospitalized for asthma at a 1,100-bed university teaching hospital in New York City during a consecutive 12-month period (September 2001 through September 2002). The hospital is the largest provider of care for the East Harlem community. Computerized hospital admission logs were used to identify all adults with a primary or secondary admission diagnosis of asthma (International

Patient Participation and Response Rates

During the study period, there were 384 hospitalizations with a primary or secondary diagnosis of asthma; 335 were confirmed asthma admissions among 250 unique patients. Of these, 218 patients met eligibility criteria, and 204 patients (94%) consented to participate. Reasons for exclusion were as follows: readmissions among study participants (n = 85), active psychiatric problems (n = 9), and admitted/discharged on the same weekend (n = 23). Of the 204 who consented, 198 patients (97%)

Discussion

In this study of a cohort of high-risk, inner-city adults hospitalized for asthma, underlying beliefs about the chronicity of disease, on which all guideline recommended care is based, varied widely. The most striking finding was that over half of the patients had the no symptoms, no asthma disease belief, suggesting that they think about their disease as an acute episodic illness. Our confidence that we have identified a dominant, deeply held, acute episodic disease belief is strengthened by

ACKNOWLEDGMENT

The authors would also like to thank Allison Cooperman, MPH, Jason Wang, PhD, Jessica Salazar, Lisa Fitzgerald, BA, Toni Sturm, MD, and Juan Wisnivesky, MD, MPH, for their contribution to the project, as well as the patients and their physicians for their goodwill and cooperation.

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    This study was funded by the Agency for Healthcare Research and Quality (RO1 HS09973) and the United Hospital Fund (010608B).

    Dr. Halm was also supported by the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program.

    An earlier version of these results were presented at the American Thoracic Society meeting on May 18, 2003.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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