The Impact of Adherence and Health Literacy on Difficult-to-Control Asthma

Abstract

Medication nonadherence and health literacy are key factors that influence the management of difficult-to-control asthma. Adherence, or the extent to which a patient follows a treatment plan, extends beyond asthma medication use and includes an appropriate inhaler technique. Assessment of adherence is critical before making a diagnosis of severe asthma and stepping up asthma therapy but is challenging in the clinical context. Health literacy, or the degree to which individuals can obtain, process, and understand health information and services needed to make health care decisions, is additionally important for asthma management and has been shown to impact medication adherence. Initiatives aiming to improve difficult-to-control asthma should address medication adherence and health literacy. Universal health literacy precautions are recommended while communicating with patients, in addition to the creation of low health literacy asthma action plans. To improve adherence, a comprehensive assessment of adherence should be conducted. Additional evidence-based interventions aiming to improve adherence focus on appropriate inhaler use, improved access to medications, the use of digital platforms, school-based asthma interventions, and the implementation of culturally tailored interventions. Data are limited regarding the use of these initiatives in patients with severe or difficult-to-control asthma.

Medication nonadherence and health literacy are key, yet under-recognized factors that influence the management of difficult-to-control asthma. This article will first discuss the impact of adherence and health literacy on difficult-to-control asthma and then provide examples of interventions that aim to improve asthma outcomes by addressing these barriers.

IMPACT OF ADHERENCE ON DIFFICULT-TO-CONTROL ASTHMA

Adherence, or the extent to which a patient follows an appropriate treatment plan from a qualified clinician, is a critical component of asthma management but is known to be suboptimal.^1,2 Rates of adherence below 50% have been reported in children,³ and rates of nondherence ranging from 30% to 70% have been reported in adults.⁴ Poor adherence has been associated with increased mortality,⁵ higher rates of health care utilization, and higher risk of rescue medication use and exacerbations.^6,7 Adherence extends beyond medication use and includes assessment of the inhaler technique and side effects of medications, avoidance of allergens or irritants, and effective communication with the health care provider (HCP).^1,8 Improving adherence in patients with asthma has been shown to improve asthma-related outcomes. For example, a prospective study of children with moderate persistent asthma showed that adherence greater than 60% led to better control.⁹

Adherence to therapy is particularly important when considering difficult-to-control asthma. Current guideline-based recommendations for asthma therapy recommend checking adherence, inhaler technique, environmental factors, and comorbid conditions before stepping up asthma medication therapy.¹⁰ The Global Initiative for Asthma suggests excluding each of these factors before making a diagnosis of severe asthma, defined as asthma that remains uncontrolled despite optimized treatment with a high-dose inhaled corticosteroid (ICS) plus a second controller, or asthma that requires a high-dose ICS plus second controller to prevent it from becoming “uncontrolled.”^11,12 Notably, distinguishing between poorly controlled or difficult-to-control asthma and severe asthma can be challenging within the clinical context given difficulties assessing patient medication adherence.¹³

CHALLENGES IN ASSESSMENT OF ADHERENCE IN PATIENTS WITH DIFFICULT-TO-CONTROL ASTHMA

Assessment of adherence to asthma therapy is challenging as there is no standardized measurement. Mechanisms to assess adherence include biochemical measurement (ie, for medications such as theophylline), clinical judgment, self-report, medication measurement, electronic medication measurement (EMM), and pharmacy database review.^1,14 Objective measurements of medication adherence such as EMM have the advantage of allowing for assessment of long-term patterns of adherence by recording and storing usage of medication over time, but they are more costly, making them less applicable for large-scale clinical use.^4,15 Subjective measures, such as patient self-report, are less expensive and can allow HCPs to collect information about patient beliefs, attitudes, and experiences with asthma medication, but have been shown to overestimate adherence.^1,4,13

IMPACT OF SEVERITY OF ILLNESS ON ADHERENCE

Evidence suggests that nonadherence may be a contributing factor to difficult-to-control asthma. In a study of patients with severe asthma who were prescribed daily oral corticosteroids, 37% completing the Medication Adherence Report Scale reported suboptimal adherence and 43% did not have detectable prednisolone or metabolites in their urine.¹⁶ Another study using EMM showed that among patients with severe asthma who were eligible for novel therapies, at least half were nonadherent to preventer therapies.¹⁷

Recent studies have tried to distinguish patients with difficult-to-control asthma from those with severe asthma. Among patients with difficult-to-control asthma, 12% fulfilled strict criteria for severe asthma, 56% had difficult-to-control asthma due to poor adherence/inhaler technique, and 32% were adherent with the correct inhaler technique but had unmanaged comorbidities.¹⁸ Another study using EMM of ICS adherence found that only 18% of children with good adherence had poor asthma control, suggestive of severe therapy-resistant asthma.¹³

FACTORS IMPACTING ADHERENCE IN PATIENTS WITH DIFFICULT-TO-CONTROL ASTHMA

A number of factors influence adherence in patients with asthma including issues related to medications, patient-related beliefs, family factors, and interactions with HCPs (Table I).¹⁹ Notably, there has been little focus in the literature on assessment of barriers to adherence specific to patients with severe asthma. Medication-related factors negatively influencing adherence include delayed effects of asthma medications, cost, and complex treatment plans.²⁰ As management of severe asthma typically includes more complicated medication regimens requiring adherence with more doses of medication, medication-related barriers to adherence may be particularly relevant for patients with severe asthma.²¹ Patient-related barriers, including patient attitudes toward treatment plans,²² psychological dysfunction, patient motivation, and belief in their caregiver, may also impact adherence. Particularly for children with asthma, family conflict and environment can significantly impact adherence.^23,24 Finally, factors related to the clinician, such as the patient-clinician relationship, may influence adherence.²⁰

TABLE I.

Factors impacting adherence^20–22

Medication-related factors

Delayed effects of asthma medications

Cost

Complex treatment plans

Adverse effects of medications

Patient-related factors

Attitude toward treatment plans

Psychological dysfunction

Patient motivation

Family environment and belief in caregiver

Stigma

Underestimation of severity of disease

Patient-clinician relationship

Perceived adequacy of communication with provider

Difficulty in scheduling

Perceived clinician disinterest

Time constraints

IMPACT OF LOW HEALTH LITERACY ON DIFFICULT-TO-CONTROL ASTHMA

Effective patient-clinician communication is also critical for the delivery of quality health care for patients with difficult-to-control asthma and may contribute to poor adherence (Table II). Often, there is an imbalance between an HCP’s communication and a patient’s comprehension, with evidence suggesting that patients may not understand or may misinterpret much of the information given to them.²⁵ Health literacy, defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions,”²⁷ is one contributor to this communication mismatch.

TABLE II.

Groups most at risk for nonadherence^25,26

Patients with severe asthma

Advanced age

Adolescents

Lower socioeconomic status

Current smoking

Earlier onset of asthma

Patients at risk for low health literacy

Elderly

Individuals with limited education

Ethnic minorities

Non-native English speakers

Individuals insured by Medicaid

Health literacy is particularly important for asthma, a disease which has periods of worsening symptoms and which requires patient engagement in self-management.^28,29 The National Assessment of Adult Literacy has found that only 12% of adults in the United States had proficient health literacy, with over one-third of US adults having difficulty with common health tasks (ie, completing health insurance applications or reading a pamphlet and understanding the importance of a screening test).^25,30 High-risk groups for low health literacy include the elderly, people with limited education, ethnic minorities, individuals who spoke a language other than English in their childhood home, and individuals insured by Medicaid.²⁵ Low literacy has also been associated with poor health status, even after adjustment for sociodemographic variables.³¹

In adult patients with asthma who required daily controller therapies, limited health literacy was associated with worse physical function, worse quality of life, and increased utilization of the emergency department (ED).³² Higher numeracy has been associated with lower lifetime risk of ED visits or hospitalizations due to asthma.³³ Low health literacy in adult patients with asthma has been associated with worse asthma knowledge scores and improper inhaler use.³⁴ In turn, improper inhaler use has been associated with uncontrolled asthma and increased asthma exacerbations in patients on fixed dose combination therapy with an ICS and a long-acting β-agonist.³⁵ Low parental health literacy has been associated with a greater likelihood of moderate persistent or severe persistent asthma in children and greater rates of ED visits and hospitalizations.³⁶ Parents with low health literacy also had less asthma-related knowledge, and their children were more likely to have worse asthma control.^36,37

ASSESSMENT OF HEALTH LITERACY IN PATIENTS WITH ASTHMA

HCPs are often unable to identify patients who have limited literacy during clinical interactions,³⁸ and health literacy may be dynamic during periods of high emotional stress. Although quick assessments of literacy have been developed for the outpatient setting,^39,40 most experts do not recommend the use of health literacy screening²⁹ for several reasons: (1) many patients with low health literacy are ashamed to ask for assistance or do not want their HCP to know about their difficulties with health literacy,⁴¹ (2) health literacy screeners are often time-consuming⁴² and do not provide direct guidance for communication, and (3) no evidence supports that literacy screening improves the delivery of health care or health outcomes.^43–45

RELATIONSHIP BETWEEN HEALTH LITERACY AND ADHERENCE

Finally, although adherence and health literacy are individually important factors impacting difficult-to-control asthma, evidence suggests that they are also connected. In adult patients with moderate or severe asthma, health literacy impacts adherence as well as asthma-related outcomes. Better health literacy, assessed as numeracy and print literacy, was significantly related to improved electronically monitored adherence, asthma control, and asthma quality of life when controlling for age and sex.⁴⁷ Adults with moderate or severe asthma and low health literacy were found to have worse measured adherence and asthma medication inhaler technique.⁴⁸ No studies were found assessing the impact of pediatric health literacy on adherence. Initiatives aiming to improve difficult-to-control asthma therefore should address both adherence and health literacy.

INITIATIVES TO EDUCATE AND SUPPORT PATIENTS WITH LOW HEALTH LITERACY AND DIFFICULTIES WITH ADHERENCE

Educational and behavioral interventions to improve adherence have been developed for patients with asthma with a focus on creating low health literacy asthma action plans. Given the episodic nature of asthma, many asthma management decisions are made at home by the patient, making understanding and subsequent adherence of asthma treatment plans imperative for optimal care. In addition, definitions of severe asthma and the guidelines for phenotype-specific management are all predicated on the assumption of treatment adherence,⁴⁹ making the accurate assessment and treatment of adherence crucial to not under- or overtreating patients with asthma.

HEALTH LITERACY PRECAUTIONS

Although health literacy screening in regular clinical practice is not recommended, experts do encourage use of universal health literacy precautions when communicating with patients.⁵⁰ The Agency for Health Care Research and Quality toolkit offers recommendations on how to improve universal health literacy, encouraging clinicians to assess their own communications skills and how their practice engages with patients in spoken communication, written communication, patient self-management, and support systems.⁵¹ For asthma care, universal health literacy is particularly important when selecting inhaler devices, teaching inhaler use, and counseling on use of an asthma action plan as studies have demonstrated that 70% of asthma action plans were written above a sixth-grade reading level.⁵² The use of professional interpreters in person or via telephone has also been shown to improve adherence and health outcomes, and reduce adverse events.^45,46,53,54 Overall, there are limited data regarding interventions that aim to improve low health literacy in individuals with asthma;^29,55 however, one 6-month intervention conducted in high-risk children with severe asthma addressing health literacy and asthma self-management skills through weekly asthma education, literacy enhancement, and life skills training showed a significant decline in hospitalizations and ED visits.⁵⁶ Many of the adherence interventions described below use tools to promote health literacy in an effort to improve adherence and health outcomes.

ADHERENCE ASSESSMENT

Assessment of adherence can be difficult in routine clinical practice, but is a necessary component of asthma treatment requiring a systematic approach and a variety of tools. When EMM is cost prohibitive or unavailable, a comprehensive assessment of adherence should include the integration of data from medical chart review and an adherence assessment with the patient and/or caregivers.^57,58 This clinical assessment of adherence informs the clinician while acting as an initial self-monitoring intervention. A medical chart review can provide information about adherence concerns, potential barriers to adherence, biochemical measurements, and/or pharmacy/prescription refill data. Biochemical measurements are best used as a preliminary screener for nonadherence as they are not available for all medications, provide little insight into patterns of adherence, may not be sensitive enough to pick up on low levels of nonadherence, and often only represent recent adherence due to short medication half-lives.⁵⁹ Measurement of fractional exhaled nitric oxide (FeNO) can also be used as a screener for nonadherence. Most studies reporting a single measurement or repeated measurements of FeNO find higher levels of FeNO in less adherent participants. Within these studies, FeNO levels are compared with alternative methods of measuring adherence such as patient self-report or electronic monitoring devices.^60–62 Notably, there is inadequate data to propose a single clinically meaningful FeNO cutoff.⁶⁰ Pharmacy/prescription refill data can also be used as a preliminary screener and to facilitate a collaborative discussion about the patient’s self-management and future treatment planning.⁶³ Notably, filling medications on time does not imply accurate administration of medication as prescribed,⁶³ and patients may use multiple pharmacies or enroll in automatic refill programs (Table III).⁶⁴

TABLE III.

Methods of assessment of nonadherence^4,57–62

Patient self-report
Pro:	Con:
• Allows for collection of information about patient beliefs, attitudes, and experiences over time	• Variable validity, may overstimate adherence
• Less expensive	• Limited by the patient’s memory
Medical chart review
Pro:	Con:
• Provides information about adherence concerns	• Concerns of nonadherence are not systematically charted
• Highlights barriers to adherence	• Less objective information about the patient’ s adherence patterns
• Provides biochemical measurements
• Provides pharmacy refill data
Pharmacy/refill prescription refill data
Pro:	Con:
• Objective data	• Cannot assess the daily pattern of medication use
Electronic medication measurement
Pro:	Con:
• Assess long-term patterns of adherence with detailed information	• Does not confirm medication was ingested
	• More costly, less applicable for large-scale clinical use
Biochemical measurements
Pro:	Con:
• Objective data	• Detection may depend on dose of medication, may need additional dose-ranging pharmacokinetic studies in lower doses of medication
	• No clear cutoff for “good” adherence
FeNO measurement and suppression
Pro:	Con:
• Objective data	• No single cutoff for “good” adherence

In addition, a comprehensive assessment of adherence requires a collaborative effort by clinicians, patients, and caregivers to improve health outcomes.⁶⁵ Adherence can be a challenging and emotional topic to broach with patients and may result in defensiveness, worry about disappointing HCPs, and efforts to avoid consequences.^59,63,66 When discussing medication adherence, a nonjudgmental interpersonal style with simple language and normalization of adherence difficulties can increase the patient’s comfort and validity of the information received.^63,67,68 This may be particularly true for patients with more severe asthma, as adherence and health outcomes do not always have a direct relationship. Overall, it is beneficial for adherence discussions to be framed as shared decision-making to improve treatment planning, adherence, and health outcomes over time.⁶⁵Adherence-based discussions should include 4 components: (1) the patient knowledge of the prescribed treatment, (2) how often the patient accurately adheres to the prescribed treatment plan, (3) how often the patient has missed or neglected treatment behaviors, and (4) the barriers that impede the patient’s adherence.⁶⁵ To improve the detail and accuracy of adherence data provided, it is important to ask about a brief and recent time frame such as a 7-day time frame for patients taking twice-daily medication.^63,65,68 Continued assessment of adherence and barriers should occur over time as these may vary as the patient develops, treatment regimens are altered, or life circumstances change.⁶⁹ Understanding these barriers is an integral component for treatment planning and implementing adherence-focused interventions.

APPROPRIATE INHALER USE

Although effective asthma treatment relies on both the regular use of medications and correct inhaler technique,^70–72 most children with asthma demonstrate significant deficiencies in the inhaler technique.⁷² Key components for effectively teaching patients to use an inhaler are explaining and demonstrating the inhaler technique and repeating this instruction over time.⁷³ The asthma education literature is not always clear on the extent to which programs assess or teach the inhaler technique⁷³ and whether they do so in a way that would be clear for patients with low health literacy. Therefore, it is not surprising that existing studies offer mixed evidence for sustained technique improvements at 12-month follow-up.⁷³ Although there is a paucity of literature regarding the inhaler technique specifically in severe or difficult-to-control asthma, a systematic review of 14 studies including adolescents and adults of all asthma severity levels suggested a negative correlation between advancing age and correct technique across metered dose inhalers and varying dry powder inhaler devices.⁷⁴ The poor inhaler technique may also be a marker of nonadherence.⁷⁵ Clinicians should continue to provide education in this area to all patients, including patients with severe or difficult-to-control asthma.

ASSESSING AND ADDRESSING ACCESS TO MEDICATIONS VIA PHARMACY DELIVERY

Many patients have difficulties filling pharmacy medications, and when patients do not have necessary medications on hand, they are unable to be adherent. Providing discharge medication delivery service so that all patients leave the hospital with their prescribed medications has been shown to lower the odds of representation to the ED within 30 days of discharge compared with patients discharged with usual care.⁷⁶ Another method for improving access to medications is to arrange pharmacy delivery so patients’ medications are delivered to their homes. Improving access to medications may be the first step to improved adherence.77–82

BEHAVIORAL INTERVENTIONS TO IMPROVE ADHERENCE

Behavioral adherence interventions among adults have been shown to be efficacious in improving ICS adherence, reducing symptoms, and decreasing unscheduled health care use.^79,80 A recent study in adults demonstrated that the more chronic care model components (eg, teaching self-management skills, providing decision support, delivery system design) that an adherence intervention contained, the greater the impact on adherence.⁸⁰ Another study, however, found no significant associations between adherence and specific behavior change techniques in the broader asthma population. The Cochrane Review of interventions for enhancing adherence to medication among pediatric and adult participants includes 13 asthma intervention studies and documented that 6 of the interventions improved adherence in asthma.⁸¹ None of these studies were specific to difficult-to-control asthma.^79,80 Given the various adherence assessment methodologies used and the mixed findings in the general asthma literature, the authors of the Cochrane Review concluded that the data were “surprisingly weak” and that “increasing effectiveness of adherence interventions would have a greater impact than improvement in specific medical treatments.”⁴⁹

Only 1 adherence intervention study has been conducted specifically with adults with difficult-to-control asthma. Over 30% of patients with difficult-to-control asthma and recent nonadherence based on prescription refill history became adherent to their medication following a concordance interview.⁸³ This interview included a conversation with patients discussing patient nonadherence and agreeing on a treatment plan to improve adherence. At 12 to 18 months of follow-up, 90% of participants remained adherent and improved adherence was associated with reductions in the prescribed daily dose of ICS, number of rescue courses of prednisolone and asthma-related hospitalizations, and increased forced expiratory volume in 1 second.⁸³

The paucity of adherence intervention studies for patients with difficult-to-control asthma extends to the pediatric asthma literature. A recent meta-analysis of 33 studies testing adherence interventions for children with asthma established that ICS adherence promotion interventions are effective among youth with asthma. However, none of the included studies specifically examined difficult-to-control asthma as a primary patient population or in secondary analyses.⁸⁴ Only 12 of the 33 studies documented asthma severity level for the participants, and the inclusion of moderate-to-severe or severe patients ranged from 10% to 94%. Although distinct from difficult-to-control asthma, a 2018 systematic review examined the impact of adherence interventions in children with severe asthma.⁸⁵ Adherence interventions for children with severe asthma included communication during pediatric visits, individualized care programs, EMM, an interactive website, and peak-flow predication with feedback. Adherence rates for children with severe asthma ranged from 28% to 67%, and interventions result in a significant improvement of adherence with rates increasing to 49% to 81%.⁸⁵ This review was limited by the lack of studies of adherence interventions in children with severe or difficult-to-control asthma, heterogeneity in the definitions of asthma types or severities, and the variety of adherence assessment tools used.⁸⁵

USE OF DIGITAL PLATFORMS TO SUPPORT ADHERENCE

Recent advancements in technology have led to an increased number of digital interventions for adherence to improve accessibility, cost-effectiveness, and customizability of interventions. One study of African American adolescents with uncontrolled asthma and prescribed ICS demonstrated improved asthma control and ICS adherence with the use of a combination of medication reminders, rewards delivered on a smartphone application, and physician feedback.⁸⁶ Most recently sensor-based electronic monitoring systems for asthma medications and symptoms have become increasingly accessible and popular in both adults and children.^87,88 Often EMM works with an mHealth app to provide a combination of features such as self-monitoring, feedback, asthma education (eg, about symptoms, medications, triggers), encouragement, and the potential to data share with the medical team. Propeller Health (Propeller Health, Madison, Wisc), for example, incorporates a Food and Drug Administration–approved sensor with a mobile app providing predictive analytics and feedback to help patients and clinicians better understand and control asthma⁸⁹ based on patient adherence. In a randomized controlled trial (RCT), the use of the Propeller Health combined with clinical feedback in children with moderate-to-persistent asthma resulted in significantly improved asthma symptom control, caregiver quality of life, and, for a smaller subset of the sample with actively transmitting sensors, adherence.⁹⁰ Similarly, in an RCT of adults with uncontrolled asthma, the use of EMM and smartphone application plus remote clinician feedback improved ICS use and decreased rescue medication use compared with a control group.⁹¹

A recent scoping review that was not limited to patients with difficult-to-control asthma demonstrated that patient-specific interactive bidirectional digital interventions reported improvements in adherence and asthma impairment in both adult and pediatric participants.⁹²

In another review of digital asthma adherence interventions for children, 87% of the interventions demonstrated improved adherence and 53% demonstrated improved outcomes, yet approximately half of the studies did not include children with severe or difficult-to-control asthma.⁹³ The studies with higher rates of moderate or severe persistent asthma (>50%) demonstrated mixed findings with an interactive web-based intervention resulting in improved adherence,⁹⁴ a daily electronic diary website resulting in decreased adherence that was better compared with a control group,⁹⁵ and MP3 recordings and motivational interviewing resulting in no statistical difference between the intervention and control group.⁹⁶ The mixed findings for the adherence interventions, specifically in the intervention samples including patients with more severe asthma, highlight the need for adherence promotion interventions to be developed for patients with severe or difficult-to-control asthma.

IMPLEMENTATION OF CULTURALLY TAILORED INTERVENTIONS

The cultural background of a patient must also be considered when implementing adherence interventions, particularly given that African Americans shoulder a disproportionate burden of the prevalence, morbidity, and mortality associated with asthma, perhaps due to lower adherence rates.^97–99 Success in performing adherence behaviors consistent with a treatment plan is the result of contextual influences interacting with social, emotional, and cognitive processes.¹⁰⁰ A recent systematic review focused on culturally tailored ICS adherence interventions for adult African Americans with asthma found only 5 studies that met their inclusion criteria, none of which was found to be effective in improving ICS adherence, though 3 studies found improved adherence in both the intervention and control groups. Asthma criteria differed across studies included in the review, with some including participants with moderate or severe asthma, and others including participants with persistent asthma.¹⁰¹

Interventions have been developed to specifically help overcome barriers such as access to care and poor patient-clinician communication in adults with moderate-to-severe asthma from low-income urban neighborhoods. One example was a patient advocate (PA) intervention, in which PAs assisted patients with scheduling visits, obtaining insurance coverage, and implementing medical advice. The PA program was found to be feasible and acceptable for patients and clinicians.¹⁰² Adults randomized to receive 6 months of the PA intervention had improved asthma control and fewer ED visits compared with the control arm, although these results did not reach statistical significance.

In pediatric asthma, school-based telemedicine interventions have been developed to improve outcomes in children with uncontrolled asthma from low-income urban areas. Specifically, a school-based intervention that allowed for the delivery and supervised administration of preventative asthma medication at school as well as telemedicine visits to ensure appropriate follow-up care resulted in more symptom-free days and fewer ED visits and hospitalizations for asthma compared with controls.¹⁰³ Another school-based intervention for children with uncontrolled asthma found that telemedicine delivery of medical and self-management visits with a pediatric psychologist reduced asthma severity in children with higher baseline severity and improved adherence to daily medications (Table IV).¹⁰⁴

TABLE IV.

Recommended interventions in difficult-to-control asthma^{50,52,57–59,73,79,80,86–90,100–104}

Adherence	Evaluative comments
Assess adherence through discussion and chart review	• Necessary components of clinical practice to ensure adherence to medications in adult and pediatric patients
Improve access to medications, self-report or electrònic follow-up, refill feedback, and peak flow prediction
Use shared decision-making
Use the objective measures of adherence, such as pharmacy refill records, electronic monitoring, written/digital tracking, or FeNO suppression	• These objective measures act as both an assessment and an intervention when self-monitoring and feedback are provided
Employ or refer for behavioral interventions	• Benefits include improvement in symptoms, health outcomes, and adherence
Consider use of digital platforms to enhance adherence	• Benefits adults and children
	• Allows for self-monitoring, feedback, asthma education
Ensure culturally sensitive interventions	• Important given higher prevalence of asthma in minority groups
Provide patient navigators and other forms of assistance	• Benefits adults with moderate-to-severe asthma in low-income urban neighborhoods
Refer to school-based asthma programs	• Benefits pediatric patients, specifically from low-income urban areas
Health literacy
Focus on use of universal health literacy precautions while communicating with patients	• Recommended by experts in all patient communication
Provide literacy-appropriate asthma action plan	• Ensure plan understood by the patient
Consider culturally sensitive interventions	• Use professional interpreters in person or via telephone
Provide patient navigators and other forms of assistance	• Ensures accurate 2-way communication
Inhaler technique
Assess inhaler technique through effective communication	• Key components for each patient visit to ensure the correct inhaler technique
Demonstrate correct inhaler use
Review at each visit

FeNO, Fractional exhaled nitric oxide.

FUTURE DIRECTIONS AND CONCLUSIONS

Overall, it is imperative for clinicians to identify patients with suboptimal adherence, understand reasons for their behavior, and implement treatment approaches aimed at improving and maintaining adherence. This is specifically true in patients with difficult-to-control asthma as many patients may be impacted by low levels of medication adherence and low health literacy. There is limited literature regarding the impact of the health literacy of pediatric patients on pediatric adherence and asthma outcomes. There may be benefit to further investigation in this area. In addition, as detailed within this article, a number of initiatives have been developed to support patients like these; however, there are limited data regarding the use of these initiatives specifically in patients with severe or difficult-to-control asthma. Future research efforts should focus on designing and testing initiatives that will benefit this patient population given a higher burden of symptoms and exacerbations, additional treatment requirements, and an increased impact on work, school, and family life. Specifically, digital interventions seem promising and research should continue to examine engagement and impact of these interventions. Behavioral, educational, and digital interventions introduce added cost, but the potential benefits of improved control resulting from addressing adherence and health literacy in patients with severe asthma may offset such cost.

Abbreviations used

ED

Emergency department

EMM

Electronic medication measurement

FeNO

Fractional exhaled nitric oxide

HCP

Health care provider

ICS

Inhaled corticosteroid

PA

Patient advocate

RCT

Randomized controlled trial