African Americans Want a Focus on Shared Decision-Making in Asthma Adherence Interventions

  • Maureen GeorgeEmail author
  • Adriana Arcia
  • Annie Chung
  • Danielle Coleman
  • Jean-Marie Bruzzese
Original Research Article


Background and Objective

Inhaled corticosteroids (ICS) reduce asthma-related morbidity and mortality. However, ICS non-adherence is more common in African American (AA) adults than White adults and explains, in part, the marked asthma disparities that AAs experience. We aimed to understand how ICS non-adherence could be addressed from the perspective of AA adults with asthma, their family, and friends.


We held six focus groups at two urban federally qualified health centers separately with adult asthma patients (n = 2), patients’ family/friends (n = 2), and patients and family/friends together (n = 2). Qualitative descriptive methodology guided the design and the conduct of focus groups. Verbatim transcripts were analyzed by three coders working independently using conventional content analysis to capture responses to interview questions and identify emergent categories.


Forty-six AA adults participated (32 patients, 14 family/friends); 67% were female. Participants stated that ICS adherence could be improved if they were heard, respected, and received patient-centered care, and if providers highlighted the risk of ICS non-adherence at clinic visits. Though not explicitly described by participants as shared decision-making (SDM), what they described included many essential elements of SDM.


Participants desired SDM and offered reasons for ICS non-adherence that could be used to inform an SDM intervention for clinical application. Strategies informed by the recipients of care and delivered by providers during routine office visits offer a scalable approach to narrowing asthma disparities experienced by AA adults.

Trial Registration identifier NCT03036267.



We would like to thank Hyejin Jeon, Dr. Richard Dorritie, and Dr. Aluem Tark for their assistance in data collection and note-taking during the focus groups.

Author Contributions

All authors have drafted the work and/or revised it critically for important intellectual content and have given final approval of the version to be published, and agree to be accountable for all aspects of the work to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. In addition, specific contributions are noted as follows: MG—conception or design of the work; acquisition, analysis, and interpretation of data for the work; AA—analysis and interpretation of data for the work; AC—acquisition, analysis, and interpretation of data for the work; DC—analysis and interpretation of data for the work; J-MB—conception or design of the work; acquisition, analysis, and interpretation of data for the work.

Compliance with Ethical Standards


This study was funded by the National Institute of Nursing Research/National Institutes of Health (1 R21 NR016507, principal investigator Maureen George).

Conflict of interest

Dr. George is a consultant to AstraZeneca, Mylan, and Teva. No conflicts exist for Drs. Arcia and Bruzzese or Ms. Chung and Ms. Coleman.

Supplementary material

40271_2019_382_MOESM1_ESM.docx (21 kb)
Supplementary material 1 (DOCX 21 kb)


  1. 1.
    Asthma. National Health Interview Survey. National Center for Health Statistics; 2017. Accessed 27 Jan 2019.
  2. 2.
    World Health Organization. Chronic respiratory diseases. Asthma. Accessed 27 Jan 2019.
  3. 3.
    Moorman JE, Akinbami LJ, Bailey CM, Zahran HS, King ME, Johnson CA, et al. National surveillance of asthma: United States, 2001–2010. Vital Health Stat. 2012;3(35):1–58.Google Scholar
  4. 4.
    Global strategy for asthma management and prevention. Global Initiatives for Asthma; 2018. Accessed 27 Jan 2019.
  5. 5.
    Boulet LP, Vervloet D, Magar Y, Foster JM. Adherence: the goal to control asthma. Clin Chest Med. 2012;33(3):405–17.CrossRefGoogle Scholar
  6. 6.
    Apter AJ, Boston RC, George M, Norfleet AL, Tenhave T, Coyne JC, et al. Modifiable barriers to adherence to inhaled steroids among adults with asthma: it’s not just black and white. J Allergy Clin Immunol. 2003;111(6):1219–26.CrossRefGoogle Scholar
  7. 7.
    Le TT, Bilderback A, Bender B, Wamboldt FS, Turner CF, Rand CS, et al. Do asthma medication beliefs mediate the relationship between minority status and adherence to therapy? J Asthma. 2008;45(1):33–7.CrossRefGoogle Scholar
  8. 8.
    US Department of Health and Human Services Office of Minority Health. Minority population profiles. Asthma and African Americans. Accessed 27 Jan 2019.
  9. 9.
    Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–7.CrossRefGoogle Scholar
  10. 10.
    Kew KM, Malik P, Aniruddhan K, Normansell R. Shared decision-making for people with asthma. Cochrane Database Syst Rev. 2017;10:CD012330. Scholar
  11. 11.
    Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, Better Outcomes of Asthma Treatment (BOAT) Study Group, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010;181(6):566–77.CrossRefGoogle Scholar
  12. 12.
    Fiks AG, Mayne SL, Karavite DJ, Suh A, O’Hara R, Localio AR, et al. Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT. Pediatrics. 2015;135(4):e965–73.CrossRefGoogle Scholar
  13. 13.
    Riley IL, Murphy B, Razouki Z, Krishnan JA, Apter A, Okelo S, et al. A systematic review of patient- and family-level inhaled corticosteroid adherence interventions in Black/African Americans. J Allergy Clin Immunol Pract. 2019;7(4):1184–1193.e3.CrossRefGoogle Scholar
  14. 14.
    Martin MA, Catrambone CD, Kee RA, Evans AT, Sharp LK, Lyttle C, Chicago Initiative to Raise Asthma Health Equity Investigative Team, et al. Improving asthma self-efficacy: developing and testing a pilot community-based asthma intervention for African American adults. J Allergy Clin Immunol. 2009;123:153–9.CrossRefGoogle Scholar
  15. 15.
    Murphy KR, Meltzer EO, Blaiss MS, Nathan RA, Stoloff SW, Doherty DE. Asthma management and control in the United States: results of the 2009 Asthma Insight and Management survey. Allergy Asthma Proc. 2012;33(1):54–64.CrossRefGoogle Scholar
  16. 16.
    Chang CH, Lewis VA, Meara E, Lurie JD, Bynum JP. Characteristics and service use of Medicare beneficiaries using federally qualified health centers. Med Care. 2016;54(8):804–9.CrossRefGoogle Scholar
  17. 17.
    George M, Pantalon MV, Sommers MLS, Glanz K, Jia H, Chung A, et al. Shared decision-making in the BREATHE asthma intervention trial: a research protocol. J Adv Nurs. 2018;75(4):876–87.CrossRefGoogle Scholar
  18. 18.
    Juniper EF, Bousquet J, Abetz L, Bateman ED. Identifying ‘well-controlled’ and ‘not well-controlled’ asthma using the Asthma Control Questionnaire. Respir Med. 2006;100(4):616–21.CrossRefGoogle Scholar
  19. 19.
    Juniper EF, O’Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 1999;14(4):902–7.CrossRefGoogle Scholar
  20. 20.
    Juniper EF, Guyatt GH, Ferrie PJ, Griffith LE. Measuring quality of life in asthma. Am Rev Respir Dis. 1993;147(4):832–8.CrossRefGoogle Scholar
  21. 21.
    Mora PA, Berkowitz A, Contrada RJ, Wisnivesky J, Horne R, Leventhal H, et al. Factor structure and longitudinal invariance of the Medical Adherence Report Scale-Asthma. Psychol Health. 2011;26(6):713–27.CrossRefGoogle Scholar
  22. 22.
    Clatworthy J, Price D, Ryan D, Haughney J, Horne R. The value of self-report assessment of adherence, rhinitis and smoking in relation to asthma control. Prim Care Respir J. 2009;18:300–5.CrossRefGoogle Scholar
  23. 23.
    Cohen JL, Mannm DM, Wisnivesky JP, Home R, Leventhal H, Musumeci-Szabo TJ, et al. Assessing the validity of self-reported medication adherence among inner-city asthmatic adults: the Medication Adherence Report Scale for Asthma. Ann Allerg Asthma Immunol. 2009;103:325–31.CrossRefGoogle Scholar
  24. 24.
    Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514–22.CrossRefGoogle Scholar
  25. 25.
    Sandelowski M. Qualitative analysis: what it is and how to begin. Res Nurs Health. 1995;18(4):371–5.CrossRefGoogle Scholar
  26. 26.
    Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–40.CrossRefGoogle Scholar
  27. 27.
    Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84.Google Scholar
  28. 28.
    Kallio H, Pietil A, Johnson M, Kangasniemi M. Systematic methodological review: developing a framework for a qualitative semi-structured interview guide. J Adv Nurs. 2016;72(12):2954–65.CrossRefGoogle Scholar
  29. 29.
    George M, Topaz M, Rand C, Sommers MS, Glanz K, Pantalon MV, et al. Inhaled corticosteroid beliefs, complementary and alternative medicine and uncontrolled asthma in urban minority adults. J Allergy Clin Immunol. 2014;134:1252–9.CrossRefGoogle Scholar
  30. 30.
    Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82.CrossRefGoogle Scholar
  31. 31.
    Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.CrossRefGoogle Scholar
  32. 32.
    Sandelowski M. Real qualitative researchers do not count: the use of numbers in qualitative research. Res Nurs Health. 2001;24:230–40.CrossRefGoogle Scholar
  33. 33.
    Guba EG. Criteria for assessing the trustworthiness of naturalistic inquiries. Educ Commun Technol J. 1981;29(2):75–91.Google Scholar
  34. 34.
    Coleman JJ. Culture care meanings of African American parents related to infant mortality and health care. J Cult Divers. 2009;16(3):109–19.Google Scholar
  35. 35.
    Okoro O, Odedina FT. Improving medication adherence in African-American women living with HIV/AIDS: Leveraging the provider role and peer involvement. AIDS Care. 2016;28(2):179–85.CrossRefGoogle Scholar
  36. 36.
    Cooper LA, Roter DL, Carson KA, Bone LR, Larson SM, Miller ER 3rd, et al. A randomized trial to improve patient-centered care and hypertension control in underserved primary care patients. J Gen Intern Med. 2011;26(11):1297–304.CrossRefGoogle Scholar
  37. 37.
    Castro EM, Van Regenmortel T, Vanhaecht K, Sermeus W, Van Hecke A. Patient empowerment, patient participation and patient-centeredness in hospital care: a concept analysis based on a literature review. Patient Educ Couns. 2016;99(12):1923–39.CrossRefGoogle Scholar
  38. 38.
    Coulter A, Parsons S, Askham J. Where are the patients in decision-making about their own care? World Health Organization; 2008. Accessed 8 Apr 2019.
  39. 39.
    Perez Jolles M, Richmond J, Thomas KC. Minority patient preferences, barriers, and facilitators for shared decision-making with health care providers in the USA: a systematic review. Patient Educ Couns. 2019;102(7):1251–62.CrossRefGoogle Scholar
  40. 40.
    Quinn S, Jamison A, Musa D, Hilyard K, Freimuth V. Exploring the continuum of vaccine hesitancy between African American and white adults: results of a qualitative study. PLoS Curr. 2016;29(8):1–27.Google Scholar
  41. 41.
    Salant T, Ganschow PS, Olopade OI, Lauderdale DS. “Why take it if you don’t have anything?” Breast cancer risk perceptions and prevention choices at a public hospital. J Gen Intern Med. 2006;21(7):779–85.CrossRefGoogle Scholar
  42. 42.
    George M, Abboud S, Pantalon MV, Sommers MS, Mao J, Rand C. Changes in clinical conversations when providers are informed of asthma patients’ beliefs about medication use and integrative medical therapies. Heart Lung. 2016;45:70–8.CrossRefGoogle Scholar
  43. 43.
    George M, Birck K, Hufford D, Jemmott LS, Weaver TE. Beliefs about asthma and complementary and alternative medicine (CAM) in low-income inner city African American adults. J Gen Intern Med. 2006;21:1317–24.CrossRefGoogle Scholar
  44. 44.
    George M, Freedman TG, Norfleet AL, Feldman HI, Apter AJ. Qualitative research enhanced understanding of patients’ beliefs: results of focus groups with low-income urban African American adults with asthma. J Allergy Clin Immunol. 2003;111:967–73.CrossRefGoogle Scholar
  45. 45.
    Cruz H, Gawrys J, Thompson D, Mejia J, Rosul L, Lazar D. A multipronged initiative to improve productivity and patient access in a Federally Qualified Health Center network. J Ambulanc Care Manag. 2018;41(3):225–37.CrossRefGoogle Scholar
  46. 46.
    Barrett SE, Puryear JS, Westpheling K. Health literacy practices in primary care settings: examples from the field. The Commonwealth Fund; 2008. Accessed 16 Jun 2019.
  47. 47.
    Arcia A, George M. Reference range number line format preferred by adults for display of asthma control status. J Asthma. 2019. Scholar
  48. 48.
    Devers KJ, Frankel RM. Study design in qualitative research—2: sampling and data collection strategies. Educ Health. 2000;3(2):263–71.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Columbia University School of NursingNew YorkUSA
  2. 2.University of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  3. 3.PhiladelphiaUSA

Personalised recommendations