In Canada, asthma affects about 2.2 million adults and 0.8 million children (12 percent of Canadian population), and is highly prevalent in the mainstream population; in particular it tends to be less well controlled among individuals of lower socioeconomic status and low income families. Asthma is also prevalent in the Canadian recent immigrant communities and constitutes a disproportionate burden of disease compared to Canadian-born individuals. Asthma affects ethnic communities differently in terms of disease-related outcomes including morbidity, and mortality, when compared with the mainstream community  . Among these populations are Mandarin, Cantonese, and Punjabi speaking immigrants who are one of the largest and fastest growing cultural communities in Canada  . Within British Columbia, the Greater Vancouver Area (GVA) is the main location for these ethnic groups  . According to the 2010 Canadian Census data, these ethno-cultural communities make up 45% of GVA’s immigrant population  .
Studies reveal that well controlled asthma requires adherence to therapy including self-management, proper use of medications, and following provider’s instruction on treatment regimens      . However, less than 50% of asthma patients adhere to medication recommended by their care providers   . Poor adherence is especially prevalent in less educated and disadvantaged groups    . Non-adherence has many implications, including preventable disease progression, increased risk of exacerbations, reduced functional ability and quality of life, and an increased risk of death      . In contrast, adherence to therapy is associated with reduced mortality and a better quality of life       .
Previous qualitative research identified multiple factors that can affect ethno- cultural patients’ ability to learn and adhere to care plans and follow caregivers’ prescribed therapy regimens, including patients’ perception of their disease, type of treatment or medication, quality of patient-provider communication, costs of medications and treatment procedures, and obstacles to comprehension and uptake posed by language and cultural barriers        . Patients from ethno-cultural communities may face barriers to health care parity due to socio-cultural
and psychological factors not addressed by the modern medical model. Consequently, these patient populations are disproportionately affected by health care disparities   .
Similar underlying determinants of proper self-management practices reported by different studies in mainstream and ethnic minority groups. While there are obvious gaps noted in both groups, including patient/care-provider communication, self-management knowledge, and medication costs, there is a knowledge gap in our understanding of how cultural beliefs and practices may effect therapy adherence among some ethno-cultural groups  . Through a cross-sectional study we investigated the link of these variables with self-re- ported adherence to asthma therapy and simultaneously examined the feasibility of involving family members, in the learning and self-management process. From our previous studies     , we observed that family members who normally give care to the patient (hereafter termed the “caregiver”) are a key health-related social support for many patients in ethnic communities. The purpose of this paper is to summarize our findings in terms of identifying: 1) the issues and concerns re adherence to asthma therapy in Cantonese
Mandarin and Punjabi patients
2) the role of culture
beliefs and family support in asthma self-management.
A participatory approach was applied to conduct the study and collect qualitative data from asthma patients in the target communities. This study was part of a larger intervention project aimed to develop and validate educational materials related to asthma management in Chinese and Punjabi communities  . The main objective of this study was to identify patients’ perceived barriers to engage actively in the management of their asthma
including self-management practices. This article summarized the participants’ self-reported attitudes
and practices related to adherence to asthma therapy and challenges and barriers to practice disease management. The study was approved by the University of British Columbia Office of Research Ethics and was registered at ClinicalTrials.gov (trial number: NCT01474928).
2.1. Participant Recruitment
A purposive sampling method was applied to enrol asthma patients who had physician diagnosed asthma
who reported using asthma medications daily
were 21 years of age or older
had immigrated to Canada within the past 5 years
resided in GVA during the study period
and spoke Mandarin
or Punjabi. Exclusion criteria included patient under the age of 21 years, their diagnosis of asthma had not been made by a doctor in Canada, inability to attend the study session because of physical limitations, inability to provide informed consent, or could not communicate in Cantonese or Mandarin. We recruited 167 asthmatic adults of whom 35 participated in group sessions to help develop the study framework and a measurement tool
40 participated in pilot testing this tool
and the remaining 87 subjects participated in the main study (85 completed all study assessments). The 75 subjects who either participated in initial group sessions or pilot study did not participate in the main study. Study participants were identified and referred to the study by respiratory and family practice physicians in the collaborating clinics in the GVA. Bilingual facilitators contacted potential candidates by the phone and explained the study objectives
and risks in the patient’s native language before recruiting them to study. They also outlined participants’ rights to participate in the study and obtained signed consent in participants’ native language.
2.2. Measurement Tool Development
Given the absence of a validated assessment tool in the target languages related to the objectives of this study
a qualitative questionnaire with 10 open-ended items (see Appendix A) to assess patients’ comprehension and adherence to physician’s instructions was developed in each target language. Initially
we invited 19 Mandarin and Cantonese and 16 Punjabi asthma patients to participate in four focus group sessions to assist in the development of the study framework and questionnaire. Patient’s perceived concerns and challenges about asthma self-management were identified during the group sessions. It was very important to engage patients in the development of the study framework to reflect the needs and views of patients to generate meaningful and practical results. The information collected from patients enabled the team to develop useful assessment tool in English
which was then translated to Chinese Simplified and Traditional and Punjabi by professional translators. Back translation was applied to develop a measurement tool in each of the target community language. The assessment tool was pilot tested with 40 asthma patients from the target communities for clarity
and comprehension of questions. In addition
for face and content validation
10 community key-informants and health professionals from the target communities were invited to review and comment on the questions. Necessary modifications were applied based on patients’ and key-informants’ feedback.
2.3. Data Collection
Data was collected during in-person interviews and the assessment tool
was administered by trained facilitators
from the target communities. Before the data collection process began
each patient signed a consent form in their native language.
2.4. Data Analyses
To analyze the data
we applied four steps in order to identify specific themes: 1) systematically read the transcripts
reviewed the participants’ responses
and compared and contrasted participant responses within groups to document emerging themes; 2) established categories and coding themes; 3) across group comparisons were made to ensure consistency in the coding; and 4) sorted responses into thematic categories. All responses were translated into English and then coded. Back translation was conducted to ensure accuracy of translation process. Initially two people conducted item coding and data extraction and discussed any disagreements. If agreed the changes were applied
otherwise a third member was involved to resolve any discrepancies and finalize the content. A professional qualitative analyser reviewed and commented on the qualitative data analysis process and necessary changes were applied accordingly. We classified recurring
emergent themes using continual comparison of the data. We added up the Mandarin and Cantonese patients in one group as “Chinese” to compare the objectives of interest with the “Punjabi” patients.
3.1. Participants’ Characteristics and Medication Use
42 Chinese and 43 Punjabi patients completed the study (aged 21 to 87 (Mean: 62.9 years
SD: 15.3 years)
42 males and 43 females). Thirty-nine participants (45.8%) used only a reliever inhaler when needed, and 46 participants (54.2%) used both reliever and controller inhalers. Among all participants
59 (69.4%) said they never received a written action plan and 22 (26%) said they never received any oral or written instructions on how to use their inhaler from their doctor or from an asthma educator. More than 50% of patients who used both reliever and controller medications were unable to distinguish between the mode of action and purpose for the different inhalers (Table 1).
3.2. Asthma Knowledge, Understanding, and Beliefs
Participants’ perspectives, knowledge, and beliefs about asthma medications, origin of their disease, and issues related to medication costs are summarized in Table 2. In general, the majority of the participants in both ethnic groups had difficulty understanding the reason for using reliever vs. controller medications and many of them blamed their doctor for their misinterpretation and indicated they never received instructions or an action plan in their language on how to correctly use inhalers and the reasons for using different medications. A suggestion made by some participants was a need to develop educational handouts and videos to be provided by an asthma educator or doctor from their community. They felt the focus of such discussions should include: medication differences, potential side effects of medications, correct use of inhalers. They also emphasized the need for educational materials that could be taken home.
Additional concerns included a belief that medication would be ineffective or cause an addiction. High cost of medication in
especially compared to the cost of similar drugs in their native countries
was a concern mentioned by many Punjabi participants. Furthermore
there were some common misconceptions among older participants in terms of the origin of their asthma and causes of disease severity. While Punjabi participants believed using non-asthma drugs might be the main reason for having severe asthma
some Chinese participants indicated side effects of asthma medications maybe the reason for their disease getting worse. Finally
although many patients identified their doctor as a main source of receiving health information
language barriers in communicating properly with care providers was expressed by both Punjabi and Chinese participants. There was a feeling that their doctor was not sympathetic enough to their cultural beliefs and practices were a commonly expressed feeling especially by female participants.
3.3. Patient Perceived Trust of Care Provider
When asked whether they would adhere to a physician’s instructions on how
Table 1. Characteristics of the patients: patients who completed the interventions (n = 85).
Table 2. Participants’ perspectives and concerns about origin of diseases, asthma management, new medication development, and patient education.
they should use their asthma therapy
there were four major themes identified by the participants that would potentially improve adherence: 1) if they liked and trusted the physician (most likely with a doctor who communicated in their native language)
2) if the physician was honest with them in explaining the side effects of the medications
3) if the physician took the time to listen to them and responded to their questions
and 4) if the physician understood the challenges the patient had with managing their asthma. The major issues and concerns regarding asthma information (accessing
etc.) are summarized below and also shown in Table 3.
3.4. Perceived Barriers to Asthma Therapy
Language and cultural barriers
lack of understanding care provider’s instruction on self-management
and concern about side effects of medicine were identified by more than 50% of participants as barriers to taking asthma therapy. While we did not evaluate the impact of social support on adherence in this study
we noticed in many instances that caregivers’ opinions influenced a patients’ decision to fully adhere to therapy regiments: “My doctor told me I can take my inhaler 8 times a day but I take only 2 times because my son believes I can become somehow resistant to it”. In addition
the patients showed interest in learning more about the medications they were taking presented in their community language. They expressed their feeling that their cultural beliefs and practices should be somehow included in the educational information: “I am an elder and many people in my age group need relevant and trusted resources for their health concerns and questions; something is needed to be changed in Canadian health system in regard to culture and language issues”.
3.5. Link between Cultural Beliefs and Practices and Asthma Therapy
There were some similarities and differences between the Chinese and Punjabi groups in their perceptions of the origins and implications of having asthma and self-management practices. For instance
a common belief amongst Chinese and Punjabi patients was that asthma is a communicable disease such as a common cold: “A lot of people in my community believe that asthma is a communicable disease”. Also many Punjabi participants expressed a feeling of being ashamed using an inhaler in public because they were concerned that others might believe they had transmissible infectious lung disease such as tuberculosis. In terms of smoking
there were different perceptions among the studied groups. While smoking was practiced openly and prevalent among Chinese patients, as they indicated smoking tends to be heavily promoted by the Chinese culture and helped to form a social connection with peers/friends and colleagues. In contrast
Punjabi patients mentioned smoking is not a practical habit in their community
specifically for women
and many indicated they prefer not to smoke in front of elders; expressing that it clashes with their religious and cultural norms. These beliefs and lack of understanding may indirectly impact patients’ decision
Table 3. Patients’ concerns and comments about their challenges related to their asthma management.
to involve in self-care of their chronic illness.
This study examined the issues and concerns of asthma management in Cantonese
Mandarin and Punjabi patients. Our findings suggest that lack of communication between patient and care provider
concerns about cost of medication
and beliefs about side effect of medications were perceived as major barriers to adherence by study participants. Such challenges and skill barriers in the target communities may increase their risk of poor outcomes. These findings confirm the results of studies that assessed the effectiveness of educational intervention on asthma outcomes in minority communities, in particular focusing on improvement of proper communication between patient and care provider and modifying disease and medication-related misunderstandings    . Indeed in our own study using appropriate educational material we saw improved asthma outcomes   .
Although we focused on overlapping themes that emerged within the studied ethno-cultural groups
it is important to identify other factors that may influence participants’ beliefs and perceptions about disease management. One of the challenges identified in this study is related to “access” to relevant information to the target communities. A suggested approach to improving accessibility of information and services is developing educational interventions and directly involving patients and caregivers  .
Another challenge was communication barriers between patients and providers. Many participants spoke of their perceptions in regards to how doctors do not respect their culture
do not respond to their needs because of being too busy
and do not speak their language. The participants indicated that due to the limited number of care providers from their communities who can communicate in their mother tongue they were facing communication isolation in the clinical encounters with English-speaking doctors. Similar issues have been reported in other studies    . Lack of proper communication resulted in patients’ feeling insufficiently instructed as many participants reported having received instructions once or not at all
and complained they never had an opportunity to receive informative education on how to use their inhalers from their care providers. These communication issues significantly complicate self- management practices  . Future medical encounters should include avoiding medical terms and using plain language by the care provider, and ideally having a fluent speaker adult family member, as navigator, when communicating with patients who have limited English proficiency     . Providers should also seek to understand patients’ cultural beliefs and practices towards the illness. Such practices will allow a more realistic representation and rigorous insights into making the doctor-patient communication process more culturally competent   .
The last but not least challenge identified by participants considered to be a barrier to therapy adherence was the cost of medications prescribed by providers. Different studies have shown involvement in the care process and trust between patient and care provider are strongly correlated to a willingness to pay for medications   . As the Canadian health care system does not provide universal insurance coverage for medications, cost is a significant factor for most patients in both mainstream and ethnic minority communities and it reduces people’s capacity to achieve consistent adherence    . The total costs for asthma treatment in Canada are likely much higher than many other developed countries   . A recent study has shown that around 64% of asthma patients in British Columbia (BC) had poorly controlled asthma and this group was responsible for 90% of the overall cost of asthma care in BC  . This financial burden was significant among participants of our study as more than 55% of study subject were over 65 years old and over 60% were unemployed or retired and relying on social insurance. Most of these participants indicated that high cost of asthma medication was a barrier to regular use of medication and suggested the possibility of reimbursement of costs by the government for low-income families  . In our study, we found that Punjabi patients were more concerned about the cost of the medications, while Chinese patients focused on the side effects of prescribed medications. Under dosing of medication was common
among both groups
but for different reasons. Punjabi participants indicated they often bought cheaper generic asthma medications from their homeland. Such practice may be related to patient’s level of education and socio-economic status, as well as disease-related beliefs and cultural norms, as is shown in other studies  . Participants burdened by medication costs were further reluctant to bear the cost of asthma medications based on their limited knowledge of their condition and the benefits of proper medication use.
Although the literature of the family’s role in supporting individuals with chronic disease, including asthma, is inconclusive about the effectiveness of family-oriented disease self-management interventions, we identified asthma management in Chinese Mandarin and Cantonese communities is a collective decision made by the patient and family members. For instance, a major influence of family member on self-management and medication adherence was facilitating the accessing and using asthma services as well as use or decline using medication, as prescribed. At various times throughout the study
we observed that many family members provided caretaking roles yet none were included in treatment plans or self-management practices. Despite this
the integration of caregivers in disease management was recognized by most participants in this study as often been lacking. Many revealed an inability to remember physicians’ instructions without their caregiver assistant and felt a distinct advantage when experiencing a worsening of their asthma when the care provider could provide the information. We believe to ensure proper adherence to therapy
including social support in self-management such as family members with a better command of English
can play a key role in improving access to needed health information. Such a consideration will enhance our understanding of culturally-based perceptions as well as useful approaches needed to formulate and design study objectives and goals      .
There are some limitations in our study. First
although we were interested in assessing family support on health outcomes we did not systematically measure family impact on the outcomes of interest
as we noticed the importance and the influence of family support on self-management practices during course of the study. Therefore
we suggest involving family members who normally provide care to the patient (named immediate care giver at home) should participate in the clinical assessment and share their thoughts and perception about asthma self-management. Next
we believe that our sample size does not have the breadth to generalize certain ethno-cultural communities’ cultural norms and health behavior
as the study patients may not be the representative of all asthma patients in the target communities. Furthermore
reliance on self-reported adherence may leave the results susceptible to response bias
such as social desirability bias. However
completion of the study by 97% of the enrolled subjects confirms that adults with asthma from Punjabi
and Mandarin communities are interested in taking an active role in their self-management and in participating in a health education intervention that can be integrated into routine asthma care. Finally, although our aim was to show the link between family support and medication adherence in asthma patients from Mandarin and Cantonese communities in Greater Vancouver area, we believe that our patients, who were recruited from collaborative clinics, do not have the breadth to generalize Chinese ethno-cultural communities’ cultural norms and health behavior in British Columbia of Canada due to the nature of the study. It is not clear to what extent the patients studied are representative of all patients in the target communities using asthma medication. Therefore, further research a larger sample size is needed to apply practical approach to recruit patients from larger Mandarin and Cantonese speaking communities in Canada to generate more inclusive and generalizable results. However, we believe the results of our study may well hold for those patients who were inclined to participate in such an educational intervention.
cultural beliefs and practices
and family support play distinct and significant roles in asthma control among Chinese and Punjabi patients
many of whom are less likely to benefit from medical directives due to language and cultural barriers. In a health system that typically favors a genomics aspect of medicine, patients are vulnerable to feeling misunderstood and diminished by healthcare providers  . Different patient groups may experience different barriers to adherence
but fear of side effects
lack of proper communication with care provider
and costs of medications were important to many participants in our study. The vast majority of the study participants expressed that language and cultural barriers as well as doctor-patient communication are the major problems when trying to connect with Canadian health system. Many participants indicated they prefer to visit a care provider from their own community who can speak their native language. Although medical interpreters are crucial in improving access to needed health care services of patients who do not speak the mainstream language, but engaging family caregivers, specifically younger generation who is fluent in the mainstream language, is crucial to the success of disease management.
Our findings show the usefulness of involving patient and caregiver in the learning process and engaging in self-management practices while providing culturally and linguistically appropriate information. Such practice can empower patient to develop and strengthen a sense of self-efficacy and confidence in managing their asthma. Patient education is the major intervention to promote self-management practices. However
to be effective
and cultural norms should be addressed in educational interventions for ethnic minority communities. Further, health education promoters should incorporate caregivers’ and patients’ perspectives about asthma therapy into patient education programs  . Such integration can promote self-management practices among patients. We anticipate the gained knowledge from this study can be applied in the future research to promote asthma self- management
and engage patients in the development and implementation of relevant interventions.
Practical implication: Our study has shown that to improve asthma self- management and therapy adherence, a provision of educational intervention to improve disease-related knowledge should be complemented with behavioral modification and empowerment techniques to enhance patients’ self-efficacy skills. To be successful, asthma self-management in ethnic communities, in particular Mandarin and Cantonese groups, does require a multifaceted approach that incorporates patients’ and family caregivers’ opinion and perspectives in designing and implementing strategies to empower patients to become informed individuals. It is also essential to improve patients’ confidence in their ability to follow physician instruction about medication adherence, as a major predictor of successful disease management practices. A fully informed patient is capable to plan and achieve self-care practice goals. The results of our study indicate that side effect, costs, cultural beliefs and practices, and social influence (such as family-oriented modeling) can be important factor in medication adherence. Therefore, appropriately developed self-management interventions, with direct involvement of patient and family members, can lead to increased patient’s disease management competency overtime. Such interventions should emphasis on three main factors to promote medication adherence in Mandarin and Cantonese communities: improve patient understanding of physician instruction by improving patient-physician proper communication; correct patient’s misconceptions about medication side effects and misperceptions about medication efficacy; and involve family members (as immediate caregivers at home) in disease management practices.
The authors would like to thank the community members
immigrant serving agencies
and key-informants from Punjabi and Chinese communities in the Greater Vancouver Area who helped us from the initial steps of this research. We would also like to kindly appreciate the Chinese and Punjabi physicians and health professionals for their contribution in the study design
and patient recruitment. The links to audio-visual materials developed in the study are:
Punjabi community video
Punjabi knowledge video
Chinese community video 1
Chinese community video 2
Chinese knowledge video
This project was funded by the Canadian Institutes of Health Research (CIHR) and partly from the Institute for Heart and Lung health at The University of British Columbia
Conflict of Interest
The authors have disclosed no conflicts of interest.
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