Relationship of Adherence to Pediatric Asthma Morbidity Among Inner-City Children Laurie J. Bauman, PhD*; Elizabeth Wright, PhD‡; Frederick E. Leickly, MD§; Ellen Crain, MD, PhD*; Deanna Kruszon-Moran, MS; Shari L. Wade, PhD¶; and Cynthia M. Visness, MA# ABSTRACT. Objectives. Morbidity from asthma among children is one of the most important US health concerns. This study examines the relationship of baseline nonad- herence to subsequent asthma morbidity among inner- city children. Methods. A multisite, prospective, longitudinal panel study was conducted of 1199 children who were aged 4 to 9 years and had asthma and their caregivers, most of whom were parents, in emergency departments and clin- ics at 8 research centers in 7 US metropolitan inner-city areas. Nine morbidity indicators were collected at 3, 6, and 9 months after baseline, including hospitalizations, unscheduled visits, days of wheeze/cough, and days of reduced activities. Results. Children whose caregivers scored high on a new measure, Admitted Nonadherence, experienced sig- nificantly worse morbidity on 8 of the 9 measures. Chil- dren who scored high on a new Risk for Nonadherence measure experienced significantly worse morbidity on all 9 morbidity measures. Multiple and logistic regres- sions found that the adherence measures had indepen- dent significant effects on morbidity. Combining the measures improved estimates of morbidity: children whose caregivers were poor on either adherence measure had worse morbidity than those with good adherence on both, eg, rate of hospitalization was twice as high, they missed more than twice as much school, had poorer over- all functioning, and experienced more days of wheezing and more restricted days of activity. Conclusions. Risk for Nonadherence and Admitted Nonadherence independently and jointly predicted sub- sequent asthma morbidity. Targeting risks for nonadher- ence may be an effective intervention strategy. Most risks can be controlled by physicians through reducing the complexity of asthma regimens, communicating effec- tively with caregivers about medication use, and correct- ing family misconceptions about asthma medication side effects. Pediatrics 2002;110(1). URL: http://www.pediatrics. org/cgi/content/full/110/1/e6; adherence, asthma, morbidity, inner-city, child. ABREVIATIONS. ED, emergency department; BSI, Brief Symptom Inventory; SD, standard deviation. D uring the past 2 or 3 decades, a significant increase in morbidity and mortality has made asthma one of the most important US health concerns. 1–3 Children, particularly inner-city chil- dren, bear a disproportionate burden of asthma mor- bidity and mortality. 4,5 The National Cooperative Inner-City Asthma Study was initiated to identify the factors associated with asthma morbidity in inner-city children, includ- ing exposure to environmental irritants and aller- gens, access to quality asthma care, psychological and social characteristics, and degree of adherence to medical regimens. This article examines the effect of adherence on asthma morbidity among inner-city children. The successful management of pediatric asthma depends in part on the extent to which caregivers and children follow the prescribed home treatment program. Guidelines for asthma care recommend avoidance of allergen/irritant exposure, regular use of preventive medications, and an action plan with rescue medications to deal with problems when they arise. 6 The consequences of nonadherence may in- clude poor symptom control, excessive -agonist use, high emergency department (ED) utilization, hospitalization, and even death. 7–10 Levels of adherence for asthma vary from 3% to 88% 11–20 and are unrelated to age, race, or gender. Most of the literature is compliance-focused and as- sumes that the patient is the problem. 20 However, data suggest that nonadherence is less dependent on individual patient characteristics than it is on the disease itself, the pharmacologic properties of the medications used, the complexity of the regimen, and patient–provider interaction. 5,21,22 Factors asso- ciated with lower adherence to the medical regimen include lack of efficacy of the medication (real or perceived); omission or drug overdose; medication taste; too many medications with multiple dosing intervals; long, demanding, or stressful treatment regimens; and incorrect prescriptions given by clini- cians. 5,22,23 Patient-related factors that may affect ad- herence include skepticism about the value of the therapy, forgetfulness, poor hearing or eyesight, de- creased mental and functional capabilities, poor quality of life and morale, lack of social support, the From the *Department of Pediatrics, Albert Einstein College of Medicine and the Children’s Hospital at Montefiore, Bronx, New York; ‡New En- gland Research Institute, Watertown, Massachusetts; §Department of Pedi- atrics, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana; National Center for Health Statistics, Hyattsville, Maryland; ¶Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio; and #Rho Federal Systems Division, Inc, Chapel Hill, North Carolina. Received for publication Mar 12, 2001; accepted Mar 18, 2002. Address correspondence to DAIT, NIAID, Solar Building Rm 4A42, 6003 Executive Blvd, Bethesda, MD 20892-7640. E-mail: bauman@aecom.yu.edu PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- emy of Pediatrics. http://www.pediatrics.org/cgi/content/full/110/1/e6 PEDIATRICS Vol. 110 No. 1 July 2002 1 of 7 by guest on October 17, 2016 Downloaded from