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 [1] . Among these populations are Mandarin, Cantonese, and Punjabi speaking immigrants who are one of the largest and fastest growing cultural communities in Canada [2] . Within British Columbia, the Greater Vancouver Area (GVA) is the main location for these ethnic groups [3] . According to the 2010 Canadian Census data, these ethno-cultural communities make up 45% of GVA’s immigrant population [4] .

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 [5] [6] [7] [8] [9] . However, less than 50% of asthma patients adhere to medication recommended by their care providers [7] [10] . Poor adherence is especially prevalent in less educated and disadvantaged groups [11] [12] [13] . 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 [14] [15] [16] [17] [18] . In contrast, adherence to therapy is associated with reduced mortality and a better quality of life [5] [6] [19] [20] [21] [22] .

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 [7] [9] [12] [23] [24] [25] [26] . Patients from ethno-cultural communities may face barriers to health care parity due to socio-cultural , behavioral , and psychological factors not addressed by the modern medical model. Consequently, these patient populations are disproportionately affected by health care disparities [13] [27] .

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 [28] . 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 [29] [30] [31] [32] , 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 [31] . 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 , beliefs , 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).

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 [6] [9] [33] . Indeed in our own study using appropriate educational material we saw improved asthma outcomes [30] [31] .

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 [34] .

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 [23] [35] [36] . 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 [1] . 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 [37] [38] [39] [40] . 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 [27] [41] .

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 [9] [24] . 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 [18] [20] [21] . The total costs for asthma treatment in Canada are likely much higher than many other developed countries [5] [21] . 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 [42] . 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 [43] . 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 [44] . 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 [45] [46] [47] [48] [49] .

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 , Cantonese , 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.

Social context , 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 [50] . 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 , patients’ beliefs , perceptions , 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 [8] . 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 , facilitators , 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 , material development , and patient recruitment. The links to audio-visual materials developed in the study are:

Punjabi community video

http://www.youtube.com/watch?v=qto8Sx2VIBM

Punjabi knowledge video

http://www.youtube.com/watch?v=SuS-YDT9vcE

Chinese community video 1

http://www.youtube.com/watch?v=LmT1qunrs1U

Chinese community video 2

http://www.youtube.com/watch?v=UhPkF6RDInU

Chinese knowledge video

http://www.youtube.com/watch?v=BJCOQK9EZ1k

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 , Vancouver.

The authors have disclosed no conflicts of interest.

Shum, M., Poureslami, I., Liu, J. and FitzGerald, J.M. (2017) Perceived Barriers to Asthma Therapy in Ethno-Cultural Communities: The Role of Culture, Beliefs and Social Support. Health, 9, 1029-1046. https://doi.org/10.4236/health.2017.97075