Asthma Treatment Adherence and Related Factors in Shanghai, China

Asthma affects over 300 million people worldwide, but half of adults and children don’t take their medication as prescribed—putting them at risk for worse symptoms, flare-ups, and hospital visits. For a chronic disease like asthma, sticking to treatment is key to staying healthy. But how well are patients in Shanghai—one of China’s most developed cities with a strong healthcare system—following their asthma plans? A 2021 study by researchers from top Shanghai hospitals sheds light on this critical issue.

Study Overview

The multi-center study included 552 adult asthma patients (18 years and older) from four tertiary and six secondary hospitals in Shanghai. All participants had been diagnosed with asthma for at least three months, could communicate clearly, and completed a detailed questionnaire. The study was approved by the ethics committee of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine (No. 2017-117), and all patients provided written informed consent.

Researchers measured adherence using the 8-item Morisky Medication Adherence Scale (MMAS-8), a widely used tool where scores ≥6 indicate “good” adherence and <6 indicate "poor" adherence. The questionnaire also asked about demographics (age, education, clinic type), asthma knowledge (five basic questions about long-term treatment), recent medication use, and reasons for skipping doses.

Key Findings: Adherence Is Far From Ideal

Only 50.2% of patients had good asthma treatment adherence—meaning nearly half weren’t following their plans consistently. Here are the most striking results:

1. Younger Adults Struggle the Most

Patients aged 18–30 were significantly more likely to have poor adherence than those over 50 (P = 0.015). This aligns with a global systematic review of 51 studies, which found young adults are the largest group of asthma patients with low adherence.

2. Clinic Type Matters—Expert Clinics Help

Patients seen in expert outpatient clinics (where doctors have advanced training in asthma) had better adherence than those in general or specialist clinics. Expert clinics often limit patient numbers, allowing more time for doctors to explain treatment and build trust—both linked to better adherence. Surprisingly, patients in specialist asthma clinics had worse adherence than those in general clinics, suggesting these clinics may not be prioritizing patient communication.

3. asthma Knowledge Gaps Drive Poor Adherence

Only 30.4% of patients correctly answered all five basic asthma questions (e.g., “Do you need long-term treatment even if you feel better?”). Patients with poor adherence knew far less:

50% of non-adherent patients understood two or fewer asthma facts (vs. fewer adherent patients).
Their awareness of key topics (like the need for ongoing treatment) was 4–18% lower than adherent patients.

A 2016 REALISE study found this lack of understanding—especially about long-term treatment—is a top cause of non-adherence worldwide.

4. Medication Regimens Play a Role

Non-adherent patients were more likely to use:

Short-acting bronchodilators (22.2% vs. 13.7% of adherent patients): These drugs relieve symptoms quickly but don’t treat underlying inflammation, which can make patients think they don’t need other meds.
Oral compound methoxyphenamine (19.6% vs. 11.9%) or traditional Chinese medicine (6.2% vs. 1.8%): Non-standard treatments were linked to lower adherence.
Four or more medications (13.8% vs. 2.5%): Too many drugs increase complexity, making it harder to stick to a plan.

Why Do Patients Skip Their Medication?

Participants chose from 13 potential reasons for poor adherence. The top causes were:

Self-defined symptom improvement (31.9%): Patients stopped taking meds because they felt better—even if their asthma wasn’t fully controlled.
Forgetting to take medication (24.5%): A common barrier for chronic disease patients.
Inconvenience of buying medicine (21.2%): Logistics like pharmacy access or refills played a role.

Non-adherent patients were far more likely to cite:

Self-perceived improvement (47.6% vs. 16.2% of adherent patients),
Forgetting doses (37.8% vs. 11.2%),
Reluctance to use inhalers long-term (25.1% vs. 9.4%),
Fear of drug dependence (22.5% vs. 10.8%).

Why This Matters for Shanghai and Beyond

Shanghai has one of China’s best healthcare systems—so these results are a wake-up call. Even in a city with strong medical resources, half of asthma patients aren’t getting the care they need. The study points to clear solutions:

Target younger adults: More asthma education for 18–30-year-olds, who may not see asthma as a long-term condition.
Prioritize expert follow-up: Encourage patients to see asthma specialists who can provide personalized care.
Simplify medications: Reduce the number of drugs prescribed when possible to lower complexity.
Improve doctor-patient communication: Help patients understand the gap between feeling better and being better—so they don’t stop treatment prematurely.

Conclusion

Asthma treatment adherence in Shanghai is not ideal, but the study offers actionable insights. For clinicians, the takeaway is simple: treat the whole patient. Listen to their concerns, explain why long-term treatment matters, and tailor plans to their lives. For patients, the message is clear: asthma is a chronic disease—sticking to your medication even when you feel well is the best way to stay healthy.

Juan Du¹,², Yu-Heng Shi³, Yu-Xiang Duan⁴, Xiao-Ru Wang⁵, Min Zhou⁶, Wen-Chao Gu⁷, Chi-Jun Wen⁸, Yi Gong⁹, Chun-Ling Du¹⁰, Bo Peng¹, Lin Sun¹, Wei Tang¹ (equal contributions from Juan Du, Yu-Heng Shi, Yu-Xiang Duan)
¹Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; ²Ruijin Hospital Northern Branch, Shanghai Jiao Tong University School of Medicine, Shanghai 201821, China; ³Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201999, China; ⁴TongRen Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200050, China; ⁵Da Hua Hospital, Xuhui District, Shanghai 200237, China; ⁶Shanghai Sixth People’s Hospital (Jinshan Branch), Shanghai 201500, China; ⁷People’s Hospital of Shanghai Pudong District, Shanghai 201200, China; ⁸Shanghai Ninth People’s Hospital (Huangpu Branch), Shanghai 200011, China; ⁹Huashan Hospital, Fudan University School of Medicine, Shanghai 200040, China; ¹⁰People’s Hospital of Shanghai Qingpu District, Shanghai 201700, China.

Published in Chinese Medical Journal 2021;134(20):2506–2508.
doi: doi.org/10.1097/CM9.0000000000001680

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