http://informahealthcare.com/jas ISSN: 0277-0903 (print), 1532-4303 (electronic) J Asthma, 2014; 51(7): 729–736 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/02770903.2014.910220

ASTHMA MANAGEMENT AND CONTROL

Does personality influence how people with asthma manage their condition? Melissa Mei Yin Cheung, B Pharm (Hons)1, Kate LeMay, B Pharm, MA2, Bandana Saini, B Pharm, M Pharm, MBA, PhD, Grad Cert Ed 1 1 Studies (Higher Edu) , and Lorraine Smith, BA (Hons), PhD Faculty of Pharmacy, The University of Sydney, Sydney, NSW, Australia and 2Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia

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1

Abstract

Keywords

Objective: Personality traits have been found to be associated with the management of chronic disease, however, there is limited research on these relationships with respect to asthma. Asthma management and asthma control are often suboptimal, representing a barrier to patients achieving good health outcomes. This explorative study aimed to investigate the relationship between correlates of asthma management and personality traits. Methods: Participants completed a postal survey comprising validated self-report questionnaires measuring personality traits (neuroticism, extraversion, openness to experiences, agreeableness, conscientiousness), asthma medication adherence, asthma control and perceived control of asthma. Relationships between asthma management factors and personality traits were examined using correlations and regression procedures. Results: A total of 77 surveys were returned from 94 enrolled participants. Significant relationships were found between personality traits and (i) adherence to asthma medications, and (ii) perceived control of asthma. Participants who scored high on the conscientiousness dimension of personality demonstrated higher adherence to their asthma medications. Women who scored low on the agreeableness dimension of personality and high on the neuroticism dimension had significantly lower perceived confidence and ability to manage their asthma. No statistically significant associations were found between asthma control and personality traits. Conclusions: Three of the five personality traits were found to be related to asthma management. Future research into the role of personality traits and asthma management will assist in the appropriate tailoring of interventional strategies to optimize the health of patients with asthma.

Control, management, treatment

Introduction With an estimated 300 million people worldwide affected by asthma [1], and the global prevalence of asthma ranging from 1–18% of the population [1], achieving good self-management and control of the condition, whilst minimising psychosocial consequences [2,3] is imperative. In Australia, asthma prevalence is high by international standards, affecting one in ten children and adults, equivalent to over 2 million Australians [2]. In spite of evidence-based treatment guidelines, asthma management is often suboptimal, leaving ample scope for improvement [4]. Although current understanding of asthma mechanisms has steered people away from psychogenesis of symptoms, manifold studies demonstrate the link between psychological and psychosocial correlates such as coping styles or family functioning and asthma management behaviors [5,6]. Emerging research has shown that personality traits may influence how people manage their asthma. Studies have

Correspondence: Dr Lorraine Smith, Faculty of Pharmacy, The University of Sydney, Building A15, Science Road, Camperdown 2006, NSW, Australia. E-mail: [email protected]

History Received 16 January 2014 Revised 6 March 2014 Accepted 26 March 2014 Published online 14 May 2014

suggested that people’s personality may influence their level of asthma control and adherence to asthma medications [7]. Similarly, self-efficacy is a correlate of both asthma control and adherence [8,9]. However, studies conducted thus far are limited, and currently there are no published studies investigating the relationship between self-efficacy and personality in asthma. Increased knowledge in these areas could help healthcare professionals better understand patient behavior, so that they can provide effective patient-centered interventions. Asthma self-management can be achieved through patientinitiated cognitive and behavioral efforts to monitor and control symptoms and prevent exacerbations [10]. Thus effective self-management involves patient confidence in their ability to accurately interpret symptoms and carry out the necessary self-care behaviors (‘‘self-efficacy’’), such as avoiding triggers and using medications [10,11]. Research has suggested that lower asthma self-efficacy is associated with worse asthma control, quality of life [8], adherence to medical regimens and more frequent hospitalizations [9]. Self-efficacy is particularly relevant to a patient’s perceived control of asthma, defined as an individual’s perceived ability to manage their asthma [12]. As self-management is a cornerstone to

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achieving asthma control [2], it is important to understand perceived control of asthma. Current asthma guidelines emphasize that the goal of treatment is to achieve and maintain control for prolonged periods [1]. Nonetheless, there is evidence that patients with asthma do not take their asthma medications corresponding to agreed recommendations from a healthcare provider, with studies reporting low adherence behaviors ranging from 25– 50% [7,13,14]. Adherence can be influenced by factors including treatment complexity, patient concerns about side effects [3,14], socioeconomic considerations [14,15], access to healthcare [3,16], comorbidities, such as depression [17], and patient knowledge and self-efficacy [3]. Despite being widely researched, medication adherence remains a challenge to optimal illness management [16]. In asthma, poor medication adherence can lead to poor asthma control, decreased quality of life and increased morbidity [18]. Research into the role of personality traits as a determinant of illness management and progression is growing as personality traits are a reliable measure of a person’s thoughts, feelings and actions [19]. It is proposed that personality can assume different roles as a predictor of disease [20]. For example, specific personality traits may play an important role in the etiology and progression of the disease; personality may lead indirectly to organic disease by influencing unhealthy behaviors such as smoking, poor nutrition and substance abuse [20]. Personality may also be associated with an individual’s psychosocial responses to illness and its treatment, for example, personality may have a profound effect on how a person responds to illness, adapts to new situations, copes with and interprets symptoms, adheres to medical regimens and reports side effects [20,21]. The Five Factor Model (FFM) [22,23], also known as the Big Five Model, is a validated, psychometrically sound representation of personality and is widely accepted in describing the taxonomy of personality [24]. The model represents five broad dimensions: neuroticism, extraversion, openness to experiences, agreeableness and conscientiousness [25]. Neuroticism refers to an individual’s tendency to experience negative affects, such as fear, sadness, embarrassment, anger, guilt and disgust. This dimension is alternatively termed ‘emotional regulation,’ referring to a person’s capacity to control their emotional responses, and has been used in the Five-Factor Personality Inventory for Children [26]. The term ‘‘neuroticism’’ is used exclusively in this paper to avoid any confusion. Gregariousness and having a focus on what is outside the self is described by extraversion. Openness to experiences refers to one’s tendency to be original and have intellectual curiosity. Altruism, compassion and cooperativeness reflect the dimension of agreeableness. Conscientiousness refers to an individual’s tendency to be self-disciplined, precise and plan behavior [17,19]. There is consensus on the reliability and validity of these dimensions [25], as well as research demonstrating that the FFM is replicable across age, gender and to some extent, cultural backgrounds [27]. Previous studies have suggested that correlates of illness management can be related to personality traits in conditions such as depression [28], type 1 diabetes [29], multiple sclerosis [30], HIV [31], and periodontal therapy [32].

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For example, the traits conscientiousness [29–31,33,34] and agreeableness [35] have been found to have positive associations with adherence to medication regimens and diabetic glycaemic control [29]. Conscientiousness also predicted HIV disease progression and patients’ coping [31]. Negative relationships have been found between adherence behavior and neuroticism [32,35] and extraversion [28]. Low or high neuroticism scores in patients with type 1 diabetes showed worse glycaemic control, suggesting a non-linear relationship may exist between these variables [29]. Conscientiousness, agreeableness and extraversion have been shown to positively correlate with self-efficacy [36,37], whilst a negative relationship between neuroticism and self-efficacy has been found [36,38]. There has been limited research investigating the relationships between personality and asthma management [5,11,37– 40], with the majority of studies conducted by one group of Swedish researchers). Higher neuroticism and lower conscientiousness and extraversion scores were found to be correlated with poorer asthma control [7,39]. Higher adherence to asthma medications has been linked with higher conscientiousness and agreeableness scores and lower neuroticism scores [41,42]. Higher extraversion scores were found to be associated with poorer adherence to peak flow monitoring in one study [40]. Differing findings have been observed between genders regarding the association between personality, adherence and asthma control. Men with higher neuroticism scores were less likely to adhere to their asthma medications, while men with higher agreeableness and conscientiousness had a higher tendency to be adherent [11,40]. There was an absence of association between adherence and personality traits in women [11,40]. Gender differences were also identified with asthma control, which has been positively correlated with conscientiousness in men only and extraversion in women only [5]. These results suggest that gender may influence the relationship between asthma management and personality traits. Despite asthma being a National Health Priority Area [43], there have yet to be any studies investigating this relationship in the Australian population. According to these previous research findings, it can be hypothesized that people who score highly on conscientiousness will have higher adherence to asthma medications, whereas those who score high on neuroticism will have lower adherence. As results from research investigating the remaining personality traits, adherence, asthma control and perceived control of asthma are mixed, limited or absent, no hypotheses can be proposed regarding the relationships between these variables. Therefore, the aim of this explorative study was to investigate the relationship between correlates of asthma management (adherence to asthma medications, asthma control and perceived control of asthma) and personality traits.

Methods Participants and recruitment The research protocol utilized in this study was approved by the University of Sydney Human Ethics Committee. Approximately 100 participants were sought based on the ratio of the number of cases to variables required for

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statistical analyses. Participants were recruited from a not-forprofit asthma organization, a medical research institute, through a poster advertisement at a university and ‘‘snowball’’ sampling. Inclusion criteria were doctor-diagnosed asthma, to be aged at least 18 years and conversant in written English. Participants answered a postal survey about their personality, asthma medication adherence, asthma control, perceived control of asthma and sociodemographics, which were returned in a reply-paid envelope. When the survey was returned, participants received a movie gift voucher as reimbursement for their time.

Questionnaire (PCAQ). This validated measure consists of 11 items rated on a 5-point Likert scale ranging from 1 ¼ ‘‘strongly agree’’ to 5 ¼ ‘‘strongly disagree’’. The PCAQ score is a sum of the 11 items (total score range 11–55), with lower scores representing perceptions of better ability and confidence to manage and control asthma [12].

Instruments

Statistical analysis

Personality

The Statistical Package for the Social Sciences (SPSS, Chicago, IL) Version 21.0 was used. Frequencies of qualitative variables and means and standard deviations of quantitative variables were calculated to explore sample characteristics. Cronbach’s alphas were computed for all administered scales to check the internal consistency of the variables. Total sample and women only analyses were conducted. Analyses were not conducted on gender comparisons, occupational status or medication use due to insufficient sample sizes. Correlation coefficients between the scores and two-tailed significance values were calculated to explore the associations between the personality dimensions and adherence to asthma medications, asthma control and perceived control of asthma. Pearson’s correlation coefficients were calculated for normally distributed variables, while the non-parametric equivalent, Spearman’s rank order correlation coefficient, was used for non-normally distributed variables. There were two sets of correlation coefficients, one for each group: the total sample (combined genders) and women only, corresponding to the personality t-score categories. Personality traits which had significant correlations with adherence, asthma control and perceived control were entered into multiple linear regression models to test the extent to which the predictor variable(s) (personality traits) explain variation in the outcome variable (adherence, asthma control or perceived control) in the presence of other variables (including age). Linear regressions were conducted based on a normal distribution of residuals. A p value of 0.05 indicated statistical significance.

The factors of the FFM of Personality were assessed using the Neuroticism, Extraversion, Openness to experiences FiveFactor Inventory-3 (NEO-FFI-3). The NEO-FFI-3 is a validated, 60-item short version of the Neuroticism, Extraversion, Openness to experiences Personality Inventory3 (NEO-PI-3). The questionnaire consists of 12 items for each of the five domains: neuroticism, extraversion, openness to experiences, agreeableness and conscientiousness. The items are rated on a 5-point Likert scale, ranging from 0 ¼ ‘‘strongly disagree’’ to 4 ¼ ‘‘strongly agree’’ (total score range 0–48). The total raw scores for each domain are converted to T-scores, which are developed from and enable comparisons with published norms of the general population [25]. Adherence to asthma medications The Medication Adherence Report Scale (MARS) was used to assess asthma medication adherence. This validated, selfreport, commonly used scale consists of 5 items of nonadherent behavior (e.g. ‘‘I forget to take them’’ and ‘‘I decide to miss out a dose’’). The items are rated on a 5-point Likert scale, ranging from 1 ¼ ‘‘always’’ to 5 ¼ ‘‘never’’ (total score range 5–25). Higher scores indicate higher levels of adherent behavior [44]. Asthma control The validated 6-item version of the Asthma Control Questionnaire (ACQ) was used to assess asthma control. This version excludes the item pertaining to FEV1, which is conducted by clinic staff and is therefore not appropriate for a postal survey. The questionnaire asks the participant to recall how their asthma was during the previous seven days and respond to the symptom and bronchodilator use questions on a 7-point scale, ranging from 0 ¼ no impairment to 6 ¼ maximum impairment. The questions are equally weighted and the ACQ score is a mean of the 6 items, and therefore between 0 ¼ totally controlled and 6 ¼ severely uncontrolled. In general, patients with a score below 1.0 will have adequately controlled asthma and above 1.0 their asthma will not be well controlled [45,46].

Sociodemographic information Data regarding gender, age, occupational status, age at diagnosis of asthma and medications for asthma (reliever, preventer and others) were gathered.

Results Participant characteristics A total of 94 participants were recruited, 77 of which returned the survey (response rate 82%). The sample consisted of more women (68.8%) than men (31.2%), aged between 20 and 91 years (mean 41.5 ± 16.2 years). The majority of participants (64.9%) received a diagnosis of asthma between the ages of 0–11 years. Reliever medication was used by 96.1% of participants, preventer medication 81.8% and other medications 31.2%. Sample socio-demographic characteristics are summarized in Table 1.

Perceived control of asthma The participants’ perceived ability and confidence regarding managing their asthma and exacerbations effectively were assessed using the Perceived Control of Asthma

Reliability analysis The instruments had acceptable internal reliability. The Cronbach’s alpha was 0.86 for neuroticism, 0.84 for

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Table 1. Characteristics of the participants (n ¼ 77).

Table 3. Correlations between adherence, asthma control, perceived control of asthma and personality traits for the total sample (n ¼ 77).

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Number (%) Gender Men Women Age, mean ± SD (range) Occupational status Bachelor or higher qualification Certificate or diploma qualification High school qualification Student Home duties Retired Missing Age at diagnosis of asthma 0–11 years 12–18 years 18 years + Reliever medication use for asthma Preventer medication use for asthma Other medication use for asthma

MARS 24 (31.2) 53 (68.8) 41.5 ± 16.2 (20–91) 38 14 4 8 1 7 5

(49.4) (18.2) (5.2) (10.4) (1.3) (9.1) (6.5)

50 6 21 74 63 24

(64.9) (7.8) (27.3) (96.1) (81.8) (31.2)

r NEO-FFI-3 Neuroticism 0.17a Extraversion 0.01a Openness 0.15a Agreeableness 0.01a Conscientiousness 0.31b

p Value

r

p Value

r

p Value

0.15 0.92 0.18 0.97 0.01

0.03b 0.06b 0.20b 0.03b 0.13b

0.82 0.59 0.08 0.77 0.25

0.22b 0.13b 0.03b 0.22b 0.12b

0.06 0.27 0.77 0.06 0.29

a

Pearson’s coefficient. Spearman’s rank coefficient. c n ¼ 76, due to missing data. b

Table 4. Correlations between adherence, asthma control, perceived control of asthma and personality traits for the women only group (n ¼ 53). MARS

Table 2. Mean scores and standard deviations for personality (NEO-FFI-3), adherence (MARS), asthma control (ACQ), perceived control of asthma (PCAQ) (n ¼ 77). Variable

Mean ± SD

NEO-FFI-3 Neuroticism Extraversion Openness Agreeableness Conscientiousness MARSa ACQb PCAQc,d

54.0 ± 10.7 50.6 ± 11.3 55.5 ± 10.1 51.8 ± 9.8 51.4 ± 10.6 18.1 ± 4.4 1.2 ± 0.98 23.7 ± 5.4

PCAQc

ACQ

r NEO-FFI-3 Neuroticism 0.25a Extraversion 0.04a Openness 0.09a Agreeableness 0.01b Conscientiousness 0.17a a

PCAQc

ACQ

p Value

r

p Value

r

p Value

0.07 0.79 0.51 0.95 0.23

0.03b 0.01b 0.17b 0.03b 0.03b

0.86 0.95 0.22 0.82 0.81

0.29b 0.21b 0.22b 0.27b 0.25b

0.04 0.15 0.13 0.05 0.08

Pearson’s coefficient. Spearman’s rank coefficient. n ¼ 52, due to missing data.

b c

extraversion, 0.76 for openness to experiences, 0.74 for agreeableness, 0.83 for conscientiousness, 0.79 for the MARS, 0.88 for the ACQ and 0.73 for the PCAQ.

that is, they were more adherent to their asthma medications. When conscientiousness was entered into a multiple linear regression model with ACQ score, PCAQ score and age, and the outcome variable as MARS score, the model explained 22% of the variance in adherence (R2 ¼ 0.22, p ¼ 0.002) (Table 5). In the model, conscientiousness ( ¼ 0.24, p ¼ 0.03) and age ( ¼ 0.37, p ¼ 0.001) were significant predictors of adherence. No other personality dimensions were significantly correlated with adherence in the total sample.

Relationships between adherence to asthma medication and personality traits

Relationships between asthma control and personality traits

The mean scores for medication adherence and the personality traits, measured by the MARS and NEO-FFI-3 respectively, are reported in Table 2. Correlations were used in the first instance to explore the hypotheses (that people with higher conscientiousness will have higher adherence to asthma medications, while those with higher neuroticism will have lower adherence), and identify the possible relationships of the remaining dimensions. A positive association between conscientiousness and adherence was found in the total group. In women, no statistically significant relationships were identified. Correlations between adherence and the personality traits are illustrated in Table 3 for the total sample and Table 4 for women only. In the total sample, participants who scored high on the conscientiousness dimension of personality demonstrated significantly higher adherence scores (r ¼ 0.31, p ¼ 0.01),

The mean scores for asthma control, measured by the ACQ, are presented in Table 2. In exploring the relationships between the personality dimensions and asthma control, the bivariate analyses carried out showed no statistically significant associations between these variables either in the total group (Table 3) or the women only group (Table 4).

a

Range 5–25, higher scores ¼ better adherence. Range 1–6, good control  1. c n ¼ 76, due to missing data. d range 11–55, lower scores ¼ higher perceived control. b

Relationship between perceived control of asthma and personality traits The mean scores for perceived control of asthma, measured by the PCAQ, are presented in Table 2. The bivariate relations identified no statistically significant relationships in the total sample (Table 3). In the women sample, negative correlations with agreeableness and positive associations with neuroticism were found (Table 4). In women, those with low agreeableness scores had significantly higher perceived control of

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Table 5. Results from multiple linear regression analyses for correlates of asthma management. Outcome variable

Predictor variables

MARS (total sample)

R2

F

0.22

4.88

p

0.42

8.47

0.40

7.79

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0.45 Agreeableness Neuroticism MARS ACQ Age

asthma scores (r ¼ 0.27, p ¼ 0.05), that is, lower perceived confidence in asthma management. A multiple linear regression model for women only with the predictors agreeableness, MARS score, ACQ score and age accounted for 42% of the variance in PCAQ score (R2 ¼ 0.42, p50.001) (Table 5). Agreeableness ( ¼ 0.30, p ¼ 0.01) and ACQ score ( ¼ 0.56, p50.001) emerged as significant predictors of perceived control in women. Also, women who scored high on the neuroticism dimension had significantly higher perceived control scores (r ¼ 0.29, p ¼ 0.04), and therefore lower perceived confidence in managing their asthma. In a multiple linear regression analysis for women only, the predictor variables: neuroticism, MARS score, ACQ score and age together explained 40% of the variance in PCAQ score (R2 ¼ 0.40, p50.001) (Table 5). Significant predictors were neuroticism ( ¼ 0.27, p ¼ 0.03) and ACQ score ( ¼ 0.59, p50.001). However, when both agreeableness and neuroticism were entered into a multiple linear regression model with MARS score, ACQ score and age (R2 ¼ 0.45, p50.001) (Table 5), only agreeableness ( ¼ 0.24, p ¼ 0.05) and ACQ score ( ¼ 0.58, p50.001) retained their significance as predictors of PCAQ score in women, whereas neuroticism was no longer significant ( ¼ 0.19, p ¼ 0.14). No other personality dimensions were associated with perceived control in women.

Discussion This is the first study to explore the relationship between correlates of asthma management (adherence to asthma medications, asthma control and perceived control of asthma) and personality traits in an Australian population. The results indicate that higher conscientiousness scores were associated with higher adherence to asthma medications, as hypothesized; and in women only, lower scores on agreeableness and higher neuroticism scores were associated with lower perceived control. Therefore, asthma management is not only a question of factors such as patient knowledge,

7.42

2.22 0.65 0.36 3.45

0.03 0.52 0.72 0.001

0.30 0.01 0.56 0.07

2.64 0.06 5.02 0.54

0.01 0.95 50.001 0.59

0.27 0.10 0.59 0.04

2.27 0.78 5.19 0.28

0.03 0.44 50.001 0.78

0.24 0.19 0.05 0.58 0.08

2.00 1.52 0.43 5.18 0.65

0.05 0.14 0.67 50.001 0.52

50.001

Neuroticism MARS ACQ Age PCAQ (women only)

0.24 0.08 0.05 0.37

p

50.001

Agreeableness MARS ACQ Age PCAQ (women only)

t

0.002

Conscientiousness ACQ PCAQ Age PCAQ (women only)



50.001

attitude, self-efficacy [10], illness perceptions and beliefs [47]. The present study indicates that the influence of different personality traits seems to be of importance in explaining a proportion of the variance in correlates of asthma management. Exploring these findings in larger scale studies could reveal findings that can equip health care providers to modulate asthma management behaviors for the mutual benefit of the patient and the health care system. The positive relationship between conscientiousness and adherence is consistent with previous studies in patients with asthma [7] and in other conditions [29–31,33,34]. High scorers of conscientiousness have a propensity to be selfdisciplined, orderly and dutiful [25], characteristics which might promote the regular use of asthma medication and hence adherent behavior. As this finding is in line with a large body of literature, it is proposed that conscientiousness, regardless of chronic condition, may be a reliable predictor of adherence. The hypothesis regarding the relationship between neuroticism and medication adherence was not supported. While a trend was found toward lower adherence related to higher neuroticism scores in the women only group, the correlation did not reach statistical significance. People who score high on neuroticism are more vulnerable to experience negative emotional states, such as fear, concern and anxiety, and are less able to cope with stress than those who score lower on the trait [25]. A concern regarding the negative consequences of medication, for example side effects, has been proposed as a predictor of poor adherence [13], and high neuroticism scorers may have a higher tendency to experience these concerns [41]. Contrary to previous research suggesting a bi-modal relationship between neuroticism scores and adherence behaviors [29], this relationship was not found in the current study. The relationship that people low on agreeableness had lower perceived control of asthma was identified in the women only sample. People who score low on agreeableness have a tendency to be skeptical, cynical and suspicious [25],

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which may explain their lack of perceived confidence in the potential for achieving effective self-management of a chronic condition such as asthma. This association is consistent with results from a study investigating self-efficacy in chronic disease management [37]. An additional finding in the female sample is that higher scorers of neuroticism, who have a propensity to be worried and concerned [25], had lower perceived control. Significant associations between perceived control and personality were identified in women only and not in the total sample, suggesting that gender may influence this relationship. Consequently, future studies need to include the gender variable to investigate this association in more detail. The present study has been the first to investigate the relationship between personality traits and perceived control (and hence self-efficacy) in asthma. However, the mechanisms by which personality could affect perceived control of asthma remain to be elucidated. Personality traits did not significantly correlate with asthma control, contrary to previous findings, for example with diabetes glycaemic control [29] and HIV disease progression [31]. Nevertheless, this relationship has been little studied in asthma and only two studies have recently analyzed this aspect [7,39]. As low medication adherence can lead to poor asthma control [18], it can be proposed that if personality traits are associated with adherence, asthma control will follow a similar trend. This aspect should be studied further in future studies. Previous research has shown that asthma control is associated with medication adherence [18] and self-efficacy [8]. The current study suggests that personality traits may influence adherence to asthma medications and perceived control. Of note, whilst previous research has proposed links between personality and asthma control [7,39], the current study did not support this. Instead, it is hypothesized that personality may not be affecting asthma control directly, rather its impact may be through perceived control (and hence self-efficacy) and adherence (Figure 1). The fact that personality traits, adherence and perceived control all Figure 1. Proposed model of relationships between personality traits and asthma outcomes.

represent thoughts, feelings and actions provides validity to this proposition. This pathway should be tested in subsequent studies with a predictive methodology and a larger sample size. These findings suggest that healthcare professionals need to be mindful of the personality traits of their patients with asthma, and consider treatment regimens that suit these individuals. Prior research has demonstrated effective models of specialist asthma care services in primary care settings [48–50], including the identification of patients at risk of suboptimal asthma control and management [50], and the provision of interventions and appropriate referrals [50,51]. These preliminary results can also pave the way for the development of focused interventions to assist people with their asthma management. For example, when working with patients who show signs of low conscientiousness, such as being easygoing, not very well-organized, careless and preferring not to make plans [25], healthcare professionals could focus on strategies to improve organization, time management and goal-setting to help increase adherence to asthma medications. Healthcare professionals could involve patients with low agreeableness, who have a tendency to be hard-headed, skeptical, proud and competitive [25] in the decision-making process and work to gain their trust. This active participation in their asthma management may minimize doubts and uncertainties the patient may have and improve their confidence in their ability to manage their asthma. For patients with high neuroticism, for example being sensitive, emotional and prone to experiencing feelings that are upsetting [25], efforts to promote active coping and reduce negative affects such as anxiety and fear may be important. These individuals are likely to have poor adherence to their asthma medications, poor perceived control and therefore could have suboptimal asthma control. The identification of these individuals at risk of poor asthma outcomes could help prevent the development of more serious consequences of asthma. Whilst it is not practical to test the personality of patients, increased understanding of the relationships between

PERSONALITY TRAITS

ASTHMA MANAGEMENT

Conscienousness

Medicaon Adh Adherence

(behaviours and related percepons)

• Self disciplined • Orderly • Dutiful

Agreeableness

ASTHMA OUTCOMES

Good Control Greater perceived control of asthma

• Altruistic • Compassionate • Cooperative

Neurocism • Sensitive • Nervous • Fearful

Poorer perceived control of asthma

Poor Control

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personality and correlates of asthma management could help healthcare professionals to tailor treatment plans and take on a more proactive approach toward helping patients. To assist healthcare professionals in identifying at-risk patients, the design of simple tools to determine a patient’s standing on clinically important personality traits would be invaluable. It is crucial to have a broad and accurate body of personality research to guide these clinical decisions. However, at present, there is little research investigating the relationship between correlates of asthma management and personality traits. Consequently, a comprehensive understanding of the role of personality in asthma management is yet to be achieved. The findings of this study form a basis to justify future research into this relationship. It is important to note that the study was subject to certain limitations. The results were based on a comparatively small number of participants, and in particular a low representation of men. Drawing on previous work of Axelsson [7], a sample size using a power calculation indicated that 294 participants would have been required. However, given the short timeframe for data collection (2 months) this was not feasible. Thus, the sample size limited the analyses which could be performed. However, this exploratory study identified statistically significant associations that can be investigated further. Secondly, it is not possible to exclude selection bias, as differences may exist between participants and non-participants in characteristics such as personality and asthma control. Thirdly, the cross-sectional design of this study and the sample size limit the ability to make causal assumptions between the variables. Strengths of this study include the relatively high response rate (82%), the use of psychometrically sound, commonly used and reliable instruments and the use of a conservative statistical analysis technique. Also, the identification of significant associations between some personality traits and correlates of asthma management provide valuable pointers for future research directions. For example, replication of the results of this study and examination of these relationships and possible mediating pathways using a longitudinal design with a larger sample could be considered in subsequent studies.

Conclusions This present study draws attention to the importance of personality in patients’ self-management of asthma (adherence to asthma medications, asthma control and perceived control of asthma). It is hoped that this exploratory study will provide the foundation for continued research into the role of personality in asthma management, which can lead to the design of evidence-based tools, interventions and approaches.

Acknowledgements The authors would like to thank Professor Carol Armour at the Woolcock Institute of Medical Research, Sara Morgan from the Asthma Foundation of New South Wales, the University of Sydney, and people and community pharmacies for their support in recruiting participants to this study. They also thank the participants for their involvement.

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Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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