TABLE 1.

Abbreviated script of the BREATHE intervention

Step	Objectives	Script and actions	Time (min)
1. Raise the subject	PCP establishes rapport by asking the patient’s permission to discuss their asthma control and health beliefs	“Would you mind taking a few minutes to talk with me about your asthma control and your use of asthma controller medicine? (insert BRAND NAME ICS)”	1.5
2. Provide feedback	PCP provides feedback to the patient based on assessments of the patient’s uncontrolled asthma and erroneous health/ICS beliefs, drawing a connection between current symptoms and ICS non-adherence. The PCP also asks the patient to make their own connections between non-adherence and current and future symptoms/outcomes. Medically accurate connections are reinforced via reflective listening by the PCP	“From what I see here your asthma is not in control.” (REVIEW ACQ SCORE) “What connection (if any) do you see between how you use your asthma controller medicine (insert BRAND NAME ICS) and having asthma that is not in control?” Show measures of asthma status again and discuss relationship between suboptimal ICS, asthma control, and risk for hospitalization/death	1.5
3. Enhance motivation	The PCP attempts to enhance the patient’s motivation to increase ICS adherence using MI techniques such as assessing his/her level of readiness to change and reasons/motives for any readiness, as well as empathy, concern, and acceptance of ambivalence about increased ICS adherence. In this step, the PCP may elicit the patient’s beliefs regarding the benefits, and negative sequelae, of their current self-management approach (pros/cons)	(Show Readiness Ruler [Figure 2]) “Based on what we just discussed, how ready might you be to increase your (insert BRAND NAME ICS) use, on a scale from 1–10, where 1 means not at all ready and 10 means totally ready?” If patient says: ≥2, ask “Why did you choose that number and not a lower one?” (Be ready to explain why you’re asking this.) If patient says: <1 or unwilling, ask- What would it take for you to become a “2”? PROBES: What would make this a problem for you? How important would it be for you to prevent that from happening? Have you not been able to do something you wanted to because of your asthma? Reflect/reiterate patients reasons for making a change	2
4. Negotiate and advise (shared decision-making)	The PCP and patient jointly consider treatment options. The PCP will actively attempt to build consensus around ICS adherence, reconciling conflicts to better align health beliefs with evidence-based guidelines. For example, if the patient uses ICS intermittently rather than twice-daily because of a fear that tolerance will develop, then the PCP will attempt to counter that belief using responses gleaned from the focus groups, as well as from national guidelines. This may include encouraging ICS use once a day as an initial short-term plan to be followed by a return visit and re-evaluation. If the patient declines to engage in SDM or declines attempts at negotiating ICS use, then the PCP and the patient agree to disagree	“What might be your next step, if any?” “If you can take more (25%; 50%) of your (insert BRAND NAME ICS) dose you will be less likely to have a serious asthma attack.” “This is what I’ve heard you say, you have agreed to…. (state actual amounts of ICS use) because you want/it will lead to…” (summarize their most motivational reasons for change). “I also suggest that you remind yourself every day of these reasons and even add new ones to the list. This is an agreement between you and yourself because we know that only you can decide it is important enough to you to make these changes.” Suggest follow-up to discuss asthma control and ICS use. Ask the patient if they have any questions and when questions have been addressed, thank patient for his/her time	2

PCP: primary care provider; ICS: inhaled corticosteroid; ACQ: asthma control questionnaire.