Whilst there has been considerable progress in understanding the pathological, physiological, immunological, clinical and genetic basis of asthma in childhood, we still have no knowledge of the basic mechanisms responsible for the development of the condition. Furthermore, whilst wheezing as a symptom may be a useful predictor, it has very considerable limitations, particularly in infants and very young children. Indeed, there is a very poor predictive value of isolated episodes of wheezing in infancy and subsequent atopic asthma at 5 and 10 years of age¹. Various attempts have been made to provide a definition of asthma based on abnormalities either in relation to clinical and physiological features of immunological and pathological abnormalities. However, the need for a precise definition depends on the reason why it is required. In the final analysis, it is the need to predict outcome and the need for treatment which dictates the clinical assessment and the use of a diagnostic label. Thus, the key requirement is to delineate predictors.

There are at least two factors which produce wheezing illness in young children, one being the physical size of the airways and the second, the degree of inflammation within their walls. Small airway calibre is associated with low birth weight, maternal smoking during pregnancy and male sex. Inflammation may either be produced by infection or allergic processes (atopy). It is clear that outcome is very different, dependent on the underlying abnormality. Those infants with small airway calibre and no atopy, may wheeze with viral infection in infancy and early childhood and then outgrow symptoms, though there may be a link with chronic obstructive lung disease in late adult life^2,3,4. The only factor which predicts the development of asthma in later childhood amongst wheezing infants is the presence of atopy as manifest by eczema or gastrointestinal food allergy and a family history of allergic disease. The specificity of this observation is relatively high, but sensitivity low. Currently, there are no other reliable markers of atopic asthma that can be used to predict its outcome in wheezing illnesses of infancy.

Justification

At least 30% of children wheeze before the age of 3 and 50% by 6. However, the prevalence of asthma by 8 is only 10-12%⁵. Nevertheless, atopic asthma is increasing in prevalence in the UK and elsewhere in the world^6,7. Furthermore, hospital admissions for acute wheezing illnesses in infants and young children have risen dramatically in the last 15-20 years⁸. Thus, increased Health Service expenditure has not been associated with improved morbidity. There have been very few good controlled trials of any therapeutic modality in the management of wheezing in infancy. Indeed, those conducted have sometimes produced negative results. Thus B-agonists, sodium cromoglycate and even steroids, inhaled or orally, have sometimes achieved no greater benefit than placebo⁹.

Description of Research

There is an urgent need to develop markers of atopic asthma amongst infant wheezers which will facilitate prediction of outcome and of response to treatment. Studies will necessarily involve following large cohorts of infant wheezers at first presentation to establish which features predict outcome. This must be followed by controlled clinical trial of a range of interventions which can include both environmental modification and pharmacotherapy. Some studies may involve recruiting high-risk new born infants who will be monitored immunologically and whose environment has been carefully studied. Others will recruit when atopic features such as eczema first develop but before asthma has evolved. A third category of patients would be those who have had their first wheeze. Predictors which will require investigation include genetic, respiratory physiological, immunological and environmental factors. With appropriate ethical considerations, some studies may involve the use of fibreoptic bronchoscopy, broncho-alveolar lavage and bronchial biopsy as the final arbiter of the presence of allergic airway inflammation.

References

1. Van Asperen P P and Mukhi A. Role of atopy in the natural history of wheeze and bronchial hyper-responsiveness in childhood. Pediatr Allergy Immunol 1994:5;178-183.

2. Martinez F D, Morgan W J Wright A L, Holberg C. and Taussig L M. Initial airway function is a risk factor for recurrent wheezing respiratory illness during the first three years of life. New Eng J Med 1991: 143;312-6.

3. Hanrahan J P, Tager I B and Segal M R. The effect of maternal smoking during pregnancy on early infant lung function. Amer Rev Respir Dis 1992:145;1129-35.

4. Barker D J P, Godfrey K M, Fall C, Osmond C, Winter P D and Shaheen S O. Relation of birthweight and childhood respiratory infection to adult lung function and death from chronic obstructive airway disease. Brit Med J 1991:303;671-675.

5. Martinex F D, Wright A I, Taussig L M, et al. Asthma and wheezing in the first six years of life. New Engl J Med 1995:332;133-138.

6. Burr M L, Butland B K, King S, and Vaughan-Williams E. Changes in asthma prevalence: two surveys fifteen years apart. Arch Dis Child 1989:64;1452-6.

7. Peat J K, van den Berg R H, Green W F, Mellis C M, Leeder S R and Woolcock A J. Changing prevalence of asthma in Australian children BMJ 1994:308;1591-1596.

8. Anderson H R. Increase in hospital admissions for childhood asthma: trends in referral, severity, and readmissions from 1970 to 1985 in a health region of the United Kingdom. Thorax 1989:44;614-9.

There is evidence that abnormalities of immunological development and pulmonary function precede symptomatic asthma. Groups of infants at high risk of asthma can be identified from a personal or family history of atopic disease and measurements of cord blood IgE may also be useful. Preventive measures should ideally begin early in life and those which are not suitable for mass implementation may be considered in the clinical management of high-risk families.

Measures which have been proposed include:

a) avoidance of parental smoking, particularly by the mother¹

b) maternal avoidance or ingested allergens during pregnancy and lactation^2,3

c) prolonged exclusive breast feeding, or use of non-allergenic milk formulae^2,3

d) avoidance or reduction of domestic allergen exposure^2,4

e) induction of immune tolerance against allergic sensitisation⁵

f) prophylactic drug therapy⁶

g) immunisation against viruses which may induce (initiate) or incite (trigger) asthma.⁷

Experimental evidence of effectiveness in preventing the development of asthma is limited to controlled trials of different modes of infant feeding and/or aeroallergen avoidance in high-risk babies ^2,3 . The results relating to the incidence of asthma and wheezing illness are inconsistent and inconclusive, but these studies are too small to exclude benefits of clinical and public health importance.

There is no consistent evidence that the severity or prognosis of asthma is altered by simple allergen avoidance measures in the home ⁴, but most of the trials conducted have been too small to demonstrate as statistically significant a modest effect which would nevertheless be of clinical and public health importance. Quantitative overview is complicated by the variety of avoidance regimes and clinical outcomes measured.

It may prove impossible to achieve a satisfactory reduction in allergen levels by environmental manipulation alone, but immunological function may be modifiable by prophylactic drug therapy in early childhood. Ketotifen, a potent antihistamine, has been evaluated with some success ⁶. The possibility of inducing immune tolerance by modifying the cytokine environment of developing helper T lymphocytes by immunotherapy has been suggested but requires further development and clinical evaluation ⁵.

Justification

Even a small relative reduction in asthma incidence or severity would translate into a substantial benefit to patients and the NHS. The opportunity to offer advice or treatment aimed at the prevention of asthma arises in the context of routine antenatal or postnatal consultations. A range of prophylactic interventions has been suggested but evidence of effectiveness is very limited.

Asthmatic patients receive advice and marketing pressure to adopt or purchase allergen avoidance regimes. These often involve considerable disruption or expense and are of uncertain clinical effectiveness.

Description of research

The research tasks relate to evaluation of interventions which can be implemented at the level of individual patients or households, and which relate to advice or treatment which can be offered by to parents or patients by health service practitioners. Preventive strategies involving environmental or public health action targeted at whole populations are excluded.

The studies required will be mainly of an experimental design, assessing the costs, risks and benefits of methods of preventing the development of asthma by modification of family lifestyle or the home environment (including allergen avoidance), or by pharmacological or immunological therapy.

Experimental studies evaluating the costs, risks and benefits of strategies for reducing the severity or improving the prognosis of asthma by modification of the home environment are also required.

References

1. Couriel J M. Passive smoking and the health of children. Thorax 1994;49:731-4.

2. Hide D W, Matthews S, Matthews L, et al. Effect of allergen avoidance in infancy on allergic manifestations at age two years. J Allergy Clin Immunol 1994;93:842-6.

3. Burr M L, Limb E S, Maguire M J, et al. Infant feeding, wheezing and allergy: a prospective study. Arch Dis Child 1993;68:724-8.

4. Colloff M J, Ayres J, Carswell F, et al. The control of allergens of dust mites and domestic pets: a position paper. Clin Exp Allergy 1992;22[Suppl 2]:1-28.

5. Holt P G. A potential vaccine strategy for asthma and allied atopic diseases. Lancet 1994;344:456-8.

6. Iikura Y, Naspitz C K, Mikawa H, et al. Prevention of asthma by ketotifen in infants with atopic dermatitis. Ann Allergy 1992;68:233-6.

The health status of patients with asthma, and thus the effectiveness of treatment for asthma, have traditionally been measured by pulmonary function, typically peak expiratory flow rates. Although this approach is entirely feasible in the context of busy clinical practice, it suffers from two main shortcomings. First it takes no account of the very different ways in which the same loss of pulmonary function affects different patients. Secondly it provides no basis for choosing between asthma and other patients in the allocation of scarce health care resources, a responsibility that falls to all purchasers in the new NHS.

Justification

Increasing acceptance of the limited value of pulmonary function as the only outcome measure for asthma has led to proposals for alternatives. These have ranged from asthma specific scales that examine the effect of the condition upon daily living^1,2 through patient centred scales for respiratory illness in general³ to general scales that cover all conditions but may not be responsive to subtle variations in pulmonary function^4,5. This diversity has led those seeking to evaluate alternative models of care for asthma to use ad hoc combinations of existing measures⁶. Thus the key issues to be addressed within their R&D priority are how valid reliable, responsive and generalisable⁷ are these measures? what optimal combinations of measures can be recommended for use in three different contexts - normal clinical practice, routine audit and monitoring, and rigorous evaluation of alternative policies?

Description of research

The problem to be researched may be divided into two stages.

The first stage is a systematic review of all outcome measures relevant to asthma it will be important to identify, not only the original paper proposing each measure, but also all subsequent papers that address the issues of validity, reliability, responsiveness and generalisability. The second stage is a multi-centre longitudinal survey of a stratified sample of asthma patients covering the full range of both severity and clinical contexts, and leading to a thorough psychometric analysis of alternative combinations of measures.

References

1. Sibbald B, Collier J, D'Souza M (1986) Questionnaire assessment of patients' attitudes and beliefs about asthma. Family Practice, 3, 37-41.

2. Hyland M E, Finnis, S, Irvine S H (1991). Scale for assessing quality of life in adult asthma sufferers. Journal of Psychosomatic Research, 35, 99-110.

3. Guyatt GH, Berman LB, Townsend M, Pugsley JO, Chambers LW (1987). A measure of quality of life for clinical trials in chronic lung disease. Thorax, 42, 773-8.

4. EuroQol Group (1990). EuroQol: a new facility for the measurement of health-related quality of life. Health Policy, 16, 199-208.

5. Garratt AM, Ruta DA, Abdalla MI, Buckingham JK, Russell IT (1993). The SF-36 health survey questionnaire: an outcome measure suitable for routine use within the NHS? BMJ, 306, 1440-4.

6. GRASSIC (1994). Integrated care for asthma: a clinical social and economic evaluation. BMJ, 308, 559-64.

The important role of clinical guidelines in improving diagnosis and management of common conditions has been recognised increasingly - by clinicians, health professionals, and by purchasers and commissioners of care ^(1,2). The UK national guidelines for asthma management ⁽³⁾ have been widely recognised as influential in this process, and they have served as the basis for production of many local and district guidelines. Nevertheless, they have been criticised as lacking a rigorous scientific approach - being based on expert consensus rather than evidence-based statements and neglecting the issue of cost-effectiveness. The more recently published WHO/NIH Global Strategy for Asthma Management presents a wider range of approaches⁴.

Justification

Asthma morbidity imposes a major burden on the NHS, Social Security, and national productivity.⁵ The vast majority of asthma is managed by general practitioners, practice nurses, general physicians, general paediatricians, and A&E staff. Effectively disseminated, evidence based clinical guidelines provide the means for directing appropriate care to all those with asthma, with consequent reductions in morbidity and mortality.⁶

Description of Research

There are several important areas of asthma management where, currently, there is no controlled trial evidence to guide clinical practice. In such areas primary research is needed. In other, systematic reviews are required to confirm or refute the recommendations of current consensus guidelines⁷. Priority areas include:

• The predictive value of PEF measurements in acute or uncontrolled asthma
• the place of chest X-ray in initial diagnosis and management of asthma
• the 'sequencing' of drugs in stepped management of asthma, particularly the place of inhaled steroids in modifying the course of the disease
• the 'stepping up' and 'stepping down' of inhaled steroids
• the positioning of long acting beta-2 agonists in routine management
• criteria for referral to secondary care

References

5. Clark T J H (Ed). The cost and occurrence of asthma. Worthing, Cambridge Medical Publications, 1990.

6. Asthma: a follow-up statement from an international pediatric asthma consensus group. Arch Dis Child 1992: 67: 240-248

Many studies of asthma therapy are relatively short term yet patients often take treatment for asthma for years if not decades. The balance of benefit to risk may be different in the short term compared to the long term as is apparent with oral steroid treatment, for example, where side effects may not be apparent for several years.

Even when side effects are well recognised there are few data to guide doctors and patients about the likelihood of side effects in relation to dose and duration of treatment ¹. It may be possible to prevent some side effects, such as osteoporosis from oral corticosteroids, if patients at risk could be identified. Corticosteroid-sparing drugs are another group of drugs where rather modest benefit has to be balanced against potentially serious side effects² and, again, long term studies are required since the drugs are only likely to be beneficial if patients can take them for several years with acceptable side effects.

Justification

It is clearly important for patients that drugs are given in doses that provide optimum efficacy in relation to safety. Drug treatment for asthma is expensive and should be cost-effective.

Description of research

There is a need for carefully designed randomised controlled trials on the benefits and risks of long term treatments for asthma in which cost-benefit is taken into account.

Although there are difficulties in undertaking long term controlled prospective studies on treatment for asthma the question of long term risk/benefit ratio is extremely important. The cost of alternative treatments should also be taken into account, with particular attention paid to the time-profile of costs and benefits, so that the most cost-effective way of controlling asthma can be determined.

References

1. Barnes P J, Pedersen S. Efficacy and safety of inhaled corticosteroids in asthma. AM Rev Respir Dis 1993;148:S1-S26.

There is evidence that a significant proportion of hospital admissions for asthma are preventable with better patient management. Particular problems include the high rate of readmissions for asthma among children under seven years¹. Educational interventions have had some success in improving patients' self management of asthma attacks and reducing in-patient admissions^2,3. However increasing the effectiveness of interventions requires greater knowledge of patients' psychological adaptation and responses to asthma, including the effects of panic-fear responses, in contributing to asthma symptoms and encouraging patients' dependence on medical services.

Maternal stress and family dynamics including parental anxiety and family tension, may also exacerbate childhood morbidity and reduce parents' ability to prevent and manage asthma attacks^4-6. The prevalence of inadequate coping responses may be greatest among socially deprived populations reflecting levels of social stress and poor maternal health, and contribute to high rates of severe asthma^7,8. These factors may be compounded by the poor availability of primary care services in some rural or inner city areas. In these circumstances, there may be higher rates of attendances at A&E departments and less effective follow-up after discharge from hospital.

Justification

Hospital inpatient services account for about half the cost to the NHS of asthma care⁷. A significant proportion of the demands on hospital services are regarded as potentially preventable with improved patient self-management, thus achieving substantial cost savings and a greater effectiveness of resource use. Enhancing patients coping ability will also reduce the burden of asthma morbidity and asthma deaths and contribute to the attainment of preventive targets.

Description of Research

Research is needed in the following areas:

• Investigations of the social and psychological influences on high rates of re-admission among adults and non-attendance for follow-up after discharge, leading to the development and evaluation of interventions to address these problems.
  
• Investigations of the significance of social and psychological influences, including parental anxiety and family stress, on hospital use among children with asthma, with the aim of identifying high risk groups and developing and evaluating strategies to promote positive coping and reduced anxiety.
  
• Investigations of the psychological impact of childhood asthma on the family, particularly its effects upon relationships and family activities, and family's attitudes and responses to the asthmatic child. These investigations should identify the need for educational and/or psychosocial supports.
  
• Comparison of the levels of self referral to A&E departments in different areas, with identification of the influences of patients' social characteristics and coping behaviours together with health service factors. This should lead to the development and evaluation of strategies to respond to patient's needs more effectively

References

1. Osman L M, Abdalla M L, Beattie J A et al (1994) Reducing hospital admission through computer supported education for patients. Grampian Asthma Study of Integrated Care (GRASSIC) Br Med J 308: 568-71

2. Hindi-Alexander M C, Cropp G J A (1984) Evaluation of a family asthma program - J Allergy Clin Immunol 74:505-10

3. Mayo P H, Richman J, Harris H W (1990) Results of a program to reduce admissions for adult asthma, Annals of Internal Medicine 112:8645-71

4. Wilson S R (1993) Patient and physician behaviour models related to asthma care. Medical Care Supp. 31 (3), MS49-60

5. Freidman M S (1984) Psychological factors associated with paediatric asthma death J.Asthma 21(2):97-117

6. Anderson H R, Bailey P A, Cooper J S, Palmer J C (1981). Influence of morbidity: illness label, and social, family, and health service factors on drug treatment of childhood asthma. Lancet; 1030-32

7. Thakker Y, Sheldon T A, Long R, Mac Faul R (1994) Paediatric in patient utilisation in a district general hospital. Archives of Disease in Child hood 70(6):488-92

Several studies have identified risk factors for severe attacks of asthma and asthma deaths^1-5. In broad terms these can be divided into those related to psychosocial factors causing problems with compliance and uptake of health care or features that identify patients who have severe episodes of asthma resulting in admissions to hospital or even intensive care, frequent symptoms or marked variations in peak flow variability; these may be due to problems with delivery of care or may be a marker of severe underlying disease.

Justification

The 10% or so of patients with more severe asthma account for much of the morbidity and mortality of the disease and consume up to 60% of the direct health costs for asthma. Thus on both health and economic grounds, targeting patients with severe disease could produce appreciable benefits. Confidential enquiries into asthma deaths have repeatedly highlighted preventable causes and that both patients, their carers and physicians underestimate disease severity and intervene too late, with insufficient therapy. This is clearly an important area in asthma management.

Description of research

Management of high risk patients is difficult. Strategies that might improve control need to be studied particularly those that improve the patients' ability to take appropriate action when their asthma starts to deteriorate or measures that improve compliance with preventative therapy. Controlled studies assessing intervention in high risk groups are needed to determine interventions that are feasible, effective and generalisable.

References

1. Wareham N J, Harrison B D W, Jenkins P F, Nicholls J, Stableforth D E. A district confidential enquiry into deaths due to asthma. Thorax 1993;48:1117-1120.

2. Rea H H, Sears M R, Beaglehole R, Fenwick J, Jackson R T, Gillies A J D, O'Donnell T V, Holst P E, Rothwell R P G. Lessons from the national asthma mortality study: circumstances surrounding death. NZ Med J 1987;100:10-13.

3. Richards G N, Kolbe J, Fenwick J, Rea H H. Demographic characteristics of patients with severe life threatening asthma: comparison with asthma deaths. Thorax 1993;48:1105-1109.

4. Campbell D A, McLennan G, Coates J R, Frith P A, Gluyas P A, Latimer K M, Luke C G, Martin A J, Roder D M, Ruffin R E, Yellowlees P M. A comparison of asthma deaths and near-fatal asthma attacks in South Australia. Eur Respir J 1994;7:490-497.

For many people with asthma the condition is no longer one viewed as a series of acute exacerbations, but is instead a longer term condition which requires regular medication and medical supervision. The patient needs to feel comfortable with their condition and medication so that they can feel responsible for their own health as well as obtain maximum benefit from the care which should be available. Where care is shared between health professionals the approach and messages given to patients should be consistent to obtain maximum compliance. Health professionals not only need to develop guided self-management plans that are tailored to meet the individual patient's needs, but they should frequently involve family members and friends.

Children with asthma are a particular area of concern. They spend considerable time at school and asthma is the commonest condition for which a child would take medication during the school day. It is essential that those with responsibility for such children (whether teachers, school nurses or midday assistants), have a similar understanding of the condition and its treatment.

Justifications

Health professionals frequently fail to offer care according to the advice contained in guidelines¹ and nurses may undertake work for which they many not have been fully trained². All specialities may not be equally good at imparting information³. Patients frequently only receive verbal information. About 50% of patients probably do not take medication in the way previously discussed with the doctor. Three-quarters of all adult admissions to hospital with acute severe asthma could probably have been avoided by different prior care⁴ and childrens' admissions can be reduced by better training of junior staff⁵.

In schools schoolteachers have been shown to have inadequate knowledge⁶ about asthma and yet are keen to know more and the school nursing service may be under utilised in those roles⁷.

Description of Research

The basic aim of this research is to discover ways of ensuring that more people with asthma benefit from the treatments that are available. What is the best way of delivery community-based patient education?. Study is needed of the best methods of implementing the advice contained within guidelines, including advice about patient education, communication and the organisation of care. Study of the best methods of eliminating barriers to education may be required, as is study of the best methods of reinforcing advice and ensuring that all who came into contact with those with asthma give uniform advice and care.

It is likely that such study would involve controlled evaluation of areas such as local asthma task forces, the implementation of school policies, enhanced training in communication skills, and introduction of new materials. Further study may be necessary of how to integrate the proven value of patient education into routine clinical care.

Reference

1. Whiteman J A & Gaduzo S C. The management of mild to moderate asthma in general practice. Br J Med Economics 1993:6 25-35.

2. Barnes G & Partridge M R. Community Asthma Clinics. 1994: Quality in Health Care: 3 133-136.

3. Tettersell M J. Asthma Patients knowledge in relation to compliance with drug therapy. 1993. Journal of Advance Nursing 18: 103-113.

4. Blainey A D, Beale A, Lomas D & Partridge M R. The cost of acute asthma - How much is preventable? Health Trends 1991: 22. 151-153.

5. Connett G J, Warde C, Wooler A & Lenney W. Audit Strategies to reduce hospital admissions for acute asthma. Arch Dis Child 1993:69. 202-205.

6. Carruthers P, Essett A F, & Barnes G. Teachers' Knowledge of asthma and asthma management in primary schools. Health Education Journal 1995. (In press).

Since the introduction of the 1990 Contract for general practice the provision of asthma care within dedicated asthma clinics has been given enormous impetus. Even modifications to the Health Promotion Regulations in 1993 continued to offer financial incentives for organised care for asthma. Isolated evaluations of nurse run clinics have indicated that such clinics may be effective in reducing asthma exacerbations, largely through increased drug treatments and consultations^1,2.

Studies indicate that the prevalence of asthma in childhood is increasing but that more effective use of treatment can reduce the level of disability and frequency of exacerbations³ and the Audit Commission suggest that an overall increase in the prescribing of inhaled corticosteroids by General Practitioners would result in fewer hospital admissions⁴.

Repeated audits of the in-patient care of acute severe asthma have shown that the processes and outcomes of care are significantly better when the patients are looked after by a team or on a ward associated with a respiratory physician, than when the firm consists only of non-respiratory general physicians ^5-10. What is not known is whether "augmented generalist" care is as good as specialist respiratory medical care.

Studies focusing on management shared between primary and secondary care could also have an important effect on the quality and continuity of care for those with more severe asthma. Patient held records are being used increasingly in conditions other than ante-natal care¹¹, and have the potential to be of value to those with asthma.

Justification

The development of primary care based asthma clinics requires more careful evaluation to determine the most effective models of care. Careful consideration is needed to ensuring that clinics provide appropriate interventions both in terms of therapies and the provision of information for patients. The prevalence of asthma dictates the importance of effective interventions in a primary care setting. In assessing the effective delivery of asthma care it is important to develop appropriate validated outcome measures.

It is also not known whether augmented generalist versus specialist respiratory care have similar high quality outcomes nor is there information on their relative costs.

(a) Primary care

It is essential that the evaluation of asthma management within primary care is closely linked to:

• Detailed evaluation of primary care based asthma clinics particularly using controlled trials.
  
• The development of suitable outcome measures.
  
• The evaluation of "shared care" arrangements between hospital units, primary health care teams, and (where relevant) asthma resource centres.
  
• The capacity to secure a reduction in "preventable" hospital admissions.
  
• The reduction of asthma related morbidity through appropriate treatment and education.
  
• An economic evaluation of models of asthma management in primary care compared with models relating to outreach services.
  
• An evaluation of the impact of specific training for doctors and nurses

(b) Hospital-based care

Studies are required which compare different approaches and costs, not only in terms of medical and nursing time, but also including ineffective treatment, duration of admission, symptom control following discharge and re-admissions.

References

1. Charlton J et al (1991) Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice British Journal of General Practice 41:232-37

2. Barritt P (1991) Measuring success in asthma care: a repeat audit. British Journal of General Practice 41:232-37

3. Anderson H R, Butland B K, Strachan D P (1994) Trends in prevalence and severity of childhood asthma. British Medical Journal Volume 308 18 June 1994 1600-1604

4. Audit Commission (1994) A prescription for improvement - towards more rational prescribing in General Practice HMSO

5. Osman J, Ormerod L P, Stableforth D E. Management of acute asthma: a survey of hospital practice and comparison between thoracic and general physicians in Birmingham and Manchester. Br J Dis Chest 1987;81:232-41.

6. Baldwin D R, Ormerod L P, Mackay A D, Stableforth D E. Changes in hospital management of acute sever asthma by thoracic and general physicians in Birmingham and Manchester during 1978 and 1985. Thorax 1990; 45: 130-4.

7. Bucknall C E, Robertson C, Moran F, Stevenson R D. Differences in hospital asthma management. Lancet 1988;I:748-50.

8. Bucknall C E, Robertson C, Moran F, Stevenson R D. Improving management of asthma: closing the loop or progressing along the audit spiral? Quality in Health Care 1992; 1:15-20.

9. Bell D, Layton A J, Gabbay J. Use of a guidance based questionnaire to audit hospital care of acute asthma. Br Med J 1991;302:1440-3.

10. Pearson M G, Ryland I, Harrison B D W. A national audit of acute severe asthma in adults admitted to hospital. Quality in Health Care 1995; 4: 24-30.

Patients' beliefs and experience of asthma and its treatment are shaped by cultural and social factors and by its impact on their everyday lives^1-5. As a result the priorities and behaviours of asthma patients diverge in important ways from medical expectations⁶. A particular concern is the high level of patients' non-adherence with asthma treatment, with approximately 50% of patients not taking preventive medications as prescribed². Special educational interventions whilst increasing knowledge have generally had little effect on patients' adherence with regular drug treatment⁷ and emphasizes the importance of a greater understanding of patient's attitudes and beliefs.

There is also evidence of differences in clinical and patient's assessments of the effects of asthma and severity of symptoms and in their goals of treatment. Patients may also place greater priority on allergen avoidance strategies in controlling asthma symptoms and desire further assistance in actively managing their condition. There is thus a need for a greater understanding of patients' perceptions and management of asthma, and of the social meanings and stigma associated with this condition. Of importance are the variations which exist among age, gender, socioeconomic and ethnic groups.

Justification

Knowledge of patients' beliefs about asthma and its' control forms the basis for improving communication between health professionals and patients and will ensure that advice and treatment decisions more closely reflect patients' own needs and priorities. This will increase the acceptability of asthma care and encourage greater self-management and responsibility, with implications for patients' quality of life and levels of morbidity.

Description of Research

Research may consist of qualitative studies or large scale surveys. Topics include:

• The extent of patients adherence with drug treatments and the influence of social and psychological factors on patient's attitudes to and use of the prescribed medications.
  
• Patients' sources of information and use of allergen avoidance measures and alternative therapies and their perceived value in controlling asthma symptoms.
  
• Evaluation of patient's satisfaction with communication and the information and advice provided by health professionals in primary care settings, with particular reference to the effects of nurse run asthma clinics on the extent to which patient needs are met.
  
• The significance of ethnicity for patients management of asthma, including the identification of differences in cultural meanings and particular needs for information.
  
• The self identity and significance of stigma for people with asthma and its' implications for individual and community based education

References

1. Donnelly J E, Donnelly W J, Thong Y H (1987) Parental perceptions and attitudes toward asthma and its' treatment: a controlled study. Social Science and Medicine 24, (5), 431-37.

2. Hunt, L M, Jordan B, Irwin S, Browner CH (1989) Compliance and the patients' perspective: controlling symptoms in everyday life. Culture, Medicine and Psychiatry 13: 314-34.

3. Nocon A, Booth T (1991) The social impact of asthma. Family Practice 8:37-41.

4. Osman L M, Russell L T, Friend J A R et al (1993) Predicting patients attitudes to asthma medication. Thorax 48:827-30.

5. Sibbald B (1989) Patient self care in acute asthma. Thorax 44, 97-101.

6. Partridge M R (1994) Objectives of asthma management: the patients view. Eur Repair Rev 4 (21):285-88.