I It has been known for nearly 20 years that teenagers with asthma are a distinct group of patients with different treatment requirements from either paediatric or adult patients; for example, because of health issues linked to smoking, peer pressure, and adherence (Price, 1996). It is estimated that around 800 000 teenagers in the UK have asthma. This figure could be higher as teenagers can have undiagnosed asthma (Siersted et al, 1998; British Thoracic Society and Scottish Intercollegiate Guidelines Network [BTS/SIGN], 2019). The prevalence and severity of allergic diseases and asthma still continues to rise in those aged 11–25 years (Venkataraman et al, 2018; Mallol et al, 2019).
Adolescence is certainly a high-risk time for many people with asthma, with an increased risk of asthma-related morbidity and mortality (Akuthota et al, 2021; Christie and Viner, 2005). Couriel (2003) suggested that the care of teenagers with asthma, who have differing needs from children or adults with the condition, has been largely neglected.
Morbidity and mortality risks
The prevalence and level of morbidity in this age group is higher than the rates in younger children (Couriel, 2003). This is thought to be due to poor symptom control, which frequently reflects poor compliance with treatment (Couriel, 2003). Forrest et al (1997) indicated that teenagers with asthma reported a greater number of comorbidities than people of the same age without asthma. Certainly, sex hormones are likely to play an important role in asthma outcomes, and asthma prevalence also changes from male to female through adolescence and adulthood (Almqvist, 2008; Bjornson and Mitchell, 2000). Therefore, adolescence is a high-risk time for people with asthma as there is an increase of asthma-related morbidity and mortality (Akuthota et al, 2021; Christie and Viner, 2005).
De Benedictis and Bush (2017) encouraged us to consider that the rapid physical, emotional, cognitive, and social changes occurring during normal adolescence can have an impact on asthma. According to Couriel (2003), the beliefs and fears of teenagers about their asthma are often unrecognised or not addressed in clinics. These vary from their general concerns about the disease and its management, to their wish for autonomy in decision-making or peer pressure and denial of their illness (Couriel, 2003). Cheng et al (2022) found that teenagers with asthma face unique challenges from issues around body image, peer acceptance and risky behaviour as they explore boundaries. These can lead to poor asthma control with under diagnosis, smoking and poor concordance (Cheng et al, 2022).
In one large systematic study by Vazquez-Ortiz et al (2020), several issues which influence self-management and ultimately health outcomes were identified, such as psychological, social/environmental, behavioural factors as well as the nature of the relationship between the patient and health-care professional. However, the authors highlighted that these are modifiable factors.
Poor asthma control
Britto et al (2011) cautioned that adolescents fail to recognise that symptoms and activity limitations contribute to their lack of control and that better control is possible. Koster et al (2015) found that adolescents did not appreciate their need of the medication or its beneficial effects. Certainly, poor concordance with taking prescribed treatment is a common issue for patients with asthma, but more so in teenagers (Horne, 2006; Yawn, 2011). If, however, there are shared care and cooperation between the patient and clinician, this should improve. We need to listen to patients’ health beliefs and to their concerns when they feel that their medication is unnecessary or when they worry about potential adverse effects, because this may stop them taking their medication (Horne, 2006). Certainly, good-quality outcomes in asthma are dependent not only on the appropriately prescribed medication, but also on patients’ ability to self-manage (Horne, 2006; Vazquez-Ortiz et al, 2020). NICE (2021) recommends that children aged 5 years and above should have a management plan that is tailored to the individual patient's concerns and goals and which should include a written action plan.
Tools to support self-management.
The challenge for teenagers with asthma is to learn how they can best self-manage their condition. Koster et al (2015) advocated the need of strategies to support self-management, which could be the use of smartphone technology with a reminder function and easy access to online information. One such example is the technology outlined by Haze and Lynaugh (2013). Although this was only a pilot, they encouraged nurses to become more involved in the development and integration of technology in their practice and to ensure there are innovative ways to enhance communication in patient care. Huang and Matricardi (2019) found that although some studies show that m-Health can improve asthma control and the patient's quality of life, others did not reveal any advantage in relation to usual care.
Forrest et al (1997) recommended the use of a tool like the generic health status instrument, the Child Health and Illness Profile, Adolescent Edition (CHIP-AE) in a holistic assessment. Ducharme et al (2008) suggested that the Paediatric Respiratory Assessment Measure is a valid clinical score for assessing acute asthma severity in teenagers. Kosse et al (2019) evaluated the ADAPT intervention which supports medication adherence in adolescents with asthma. They found that there was a positive effect of the intervention on medical adherence but not on overall outcomes.
‘… a person-centred approach to all aspects of care is central to supporting these patients to self-manage their asthma and therefore minimise concerns around morbidity and mortality.’
In a systematic review by the European Academy of Allergy and Clinical Immunology (EAACI) Roberts et al (2020) identify a number of modifiable factors that influence the quality of life, self-efficacy, and other outcomes in adolescents with asthma. They define five main themes which are outlined in Table 1.
Table 1. Modifiable factors and quality of life
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Source: Adapted from Roberts et al, 2020
Holley et al (2018) highlighted the crucial importance for health-care professionals to facilitate open, inclusive, two-way consultations in their educational programmes. This empowers adolescents to improve their asthma self-management (Holley et al, 2018).
Transition of care
Another important aspect of self-management is the effective transition from child to adult services. Effective transition of care involves preparing teenagers with asthma to take responsibility for the management of their own condition and to support them to negotiate the health system (BTS/SIGN, 2019). Transition of care from the paediatric to the adult clinic remains a challenge for staff, as there is a lack of consensus over the best method of achieving this. Effective transition means that clinicians have educated and empowered these individuals to manage as much of their asthma care as they are capable of, while also supporting the family to gradually hand over responsibility for management to their child (BTS/SIGN, 2019).
Substantial deficiencies in the current approach to transition have been identified by a recent EAACI task force (Roberts, 2020). Certainly, some of the psychosocial changes that occur during puberty can complicate or impede transition from child to adult services (Withers and Green, 2019). Issues that stand out are smoking, drug use, new mental health issues and poor concordance to treatment (Withers and Green, 2019). The transition of care from child to adult services needs to be planned and age appropriate (Ödling et al, 2020; Nanzer et al, 2021) to prevent the risk of long-term health consequences (Couriel, 2003; Nanzer et al, 2021). Robinson et al (2022) found that the best time to start this transition depends on several factors such as their mental and physical development, disease activity, health literacy, adherence to treatment, autonomy in disease management, family's socio-economic circumstances and education situation. They recommended that staff use a transition readiness questionnaire, which has been developed for other long-term conditions. Much like shared decision-making, there needs to be a co-production and collaborative approach from all stakeholders for a successful and smooth transition process (Robinson et al, 2022). According to the results of Khaleva et al's (2020) large European study, many of the allergy services do not have a transition process to support adolescents to become independent patients. There is therefore a need to ensure adequate training to help nurses working in these services to deliver patient-centred transitional support to teenagers with asthma.
The EAACI indicates that any clinical service for adolescent and young adult patients has to include early transition using a structured, multidisciplinary approach, ensuring the patients fully understand their condition and have the necessary resources (Roberts et al, 2020).
Conclusions
De Benedictis and Bush (2017) in their review of the literature recommend that the caring attitude of health providers, correct prescribing and appropriate educational programmes are key to the successful management of asthma in teenagers. We can see from this review that a person-centred approach to all aspects of care is central to supporting these patients to self-manage their asthma and therefore minimise concerns around morbidity and mortality. Certainly, the use of tools that encompass the issues this age group face has been widely accepted.
KEY POINTS
- The figures of teenagers with asthma is rising.
- Adolescence is a high risk time for people with asthma, marked by an increased risk of asthma-related mortality and morbidity.
- Adolescence is a period of rapid physical, emotional, cognitive, and social changes which can have an impact on asthma.
- Poor concordance with taking treatment as it has been prescribed is a common issue for patients with asthma, and more so in teenagers.
- There is a need for effective transition of care, which prepares teenagers with asthma to take responsibility for the management of their own condition and to support them to negotiate the health system.
REFLECTIVE QUESTIONS
- Why do you think adolescence is a high risk time for people with asthma?
- How do you think you can implement shared decision-making and self-management principles with your clients with asthma?
- The European Academy of Allergy and Clinical Immunology (EAACI) outlined in Roberts et al (2020) suggested that there are a number of modifiable factors that influence the quality of life, self-efficacy, and other outcomes in adolescents with asthma. What are they? How do you think you can apply them to the care you deliver for your patients.