Asthma Care Revolution: The Power of Multi-Level Models
- kmallett3
- Mar 6
- 8 min read
What if I told you that there is a medical condition that is affecting 2.8 million Canadians and 9.7% of Albertans (Adatia et al. 2024). It effects the daily lives of those living with it and up to 90% are not getting the medication they need to treat it properly (LungSask, 2022). No, it’s not something foreign, exotic, or difficult to treat- it’s the common respiratory disease known as asthma. Through this article I will explore the ways that a multi level model of care and influence is relevant to those with asthma. Figure 1 (Institute of Medicine, 2010, as cited in Galea, 2015) illustrates the diverse levels of influence in promoting asthma treatment. This image, which was originally cited in a cardiovascular health lens, I have found to be a more complete picture of influential factors for people with asthma.
As we can see in Figure 1, there are many factors that can influence someone’s experience with a condition like asthma. We will focus on the levels of individual, societal, environmental, institutional and legislative and how they influence and interact with one another.
Individual
We will first explore the factors an individual faces and some they have potential control over. Why potential control? As stated in the introduction, up to 90% of people with asthma are not getting the current treatment they need. There is nothing nefarious in the reasoning, it is simply that the individual is not taking, or using their medication properly (LungSask, 2022). Factors on the level of the individual are not only behavioural. It is important to examine and consider other factors, such as:
Genetics
Genetics are an inherent, uncontrollable risk factor in an asthma diagnosis that contribute to the susceptibility and/ or severity of the diagnosis (Canino, et.al., 2009).
Behaviour
Once a person is diagnosed with asthma, their behaviours are something within their control. Taking medication as prescribed with proper technique, maintaining a healthy lifestyle and being active in their own care are a few behavioural factors. Education and training are helpful ways to encourage adaptive behaviours.
Psychological Factors
In individuals with asthma, it is 6 times more likely that they will have anxiety or depression, compared to the regular population (Stanescu et.al., 2019). With that, a person would be more likely to engage in maladaptive behaviours that would be detrimental to their care. For instance, not participating in their wellness or keeping a healthy lifestyle. Mental health supports play an important role in addressing phycological needs.
Health Risk Factors
If multiple health related risk factors are present, it can lead to a more problematic treatment of asthma. For instance, people with asthma and a high body mass index (BMI) have been found to score lower on Quality-of-Life scales. This can affect the self-management and illness perceptions leading to a diminished state of health. For people with other health risk factors non- pharmacological treatments such as a change in lifestyle, physical activity promotion or additional education should be promoted (Stanescu et.al., 2019).
Physical Limitations
Living with asthma creates physical limitations. Overexertion can trigger an asthma flare up while under exertion makes it more likely an overexertion will happen when a person participates in any type or level of intensity of physical activity (Stanescu et.al., 2019)
The individual influences are those that directly impact a person. However, we neither live in a bubble nor a vacuum and daily find ourselves impacted by other factors. The next level of impact is the ‘social’ level. The company we keep and the communities we live in create a unique environment for each person.
Societal
As we noted on the individual level, the ways in which we live and treat ourselves can impact our outcomes of a chronic diagnosis. How, where and with whom we live also shapes those factors. Social factors include the following:
Socio economic status
People with low socio-economic status (SES) have higher rates of asthma than higher income earners. Those with low SES are also more likely to have poor health in general, decreased life expectancy and be more likely to engage in risky behaviours like smoking (Canino et.al., 2009).
Culture
The culture a person belongs to can have a drastic effect on asthma rates and outcomes. Many minority communities live in neighborhoods that live below the poverty line. While poverty has been associated with general poor health outcomes, when it comes to asthma, studies have shown that there is an association between neighborhood poverty and increased prevalence of asthma independent of individual risk factors (Canino et.al., 2009).
Neighborhood and Living Conditions
People with low SES frequently live in neighborhoods that expose them to higher rates of environmental toxins, violence and stress. These factors have also been shown to affect health independent of individual risk factors (Canino et.al, 2009).
Ways to address the social influences can be difficult to influence on an individual level. Supports for low-income populations are required to ensure that people have a safe, healthy place to live and can earn a living wage. Social influences affect our daily lives and can be difficult for an individual to act upon. It can be better influenced at the level of institution and policy.
Environment
Similar to living conditions, the environment is an important influencer in the lives of people with asthma. Living in parts of the world that are overly polluted with lots of smog will be detrimental to someone with asthma. Humidity, extreme heat, exposure to allergens, smoke from forest fires. While it is not known if pollutants cause asthma, levels of pollution in the air have been correlated with increased rates of respiratory illnesses (Canino et.al., 2009).
Environment is difficult to influence at the level of individual or society, though not impossible. Promoting clean air practices, reducing the amount of harmful chemicals used at home and in the workplace can impact the quality of the environment we live in. It is much more effectively addressed at the institutional and policy levels as there; real change can be enacted at a much larger scale.
Institutional
Here is where the healthcare industry truly gets involved. Direct patient care and education, providing prescription medication, providing education about asthma and advocating for policy creation or change. As much as the aim of healthcare is to provide care, there are risk factors at this level:
Practice bias and stereotyping
Under classification of asthma symptoms and severity can occur when communication between a physician and patient occurs. This has been observed in minority populations, where language barriers play a part (Canino et.al., 2009). Health care providers could mitigate this by providing a translator to the person to limit misunderstandings.
Stereotyping could play a part in decreased quality of care. It is possible that providers intend to provide equitable care while unconsciously acting to confirm their stereotypes. In an example illustrated by Canino et.al. they discuss that some physicians hold a belief that African-Americans and other minority groups are less likely to use their medication or follow a treatment plan. While this may be true, this information if reflective of a group of people and not an individual. These stereotypes can influence physician behaviour seeing them prescribe less medication and not promote preventative education (Canino et.al., 2009). Ways to mitigate this risk are for physicians to understand their patients as individuals will be able to identify and assist in addressing any barriers the patient is facing.
Ignorance
In the statistic that I provided earlier where up to 90% of people with asthma are using medications incorrectly, it also states that this includes physicians (LungSask, 2022). While we cannot expect family physicians to be knowledgeable in all indications of asthma treatment or health in general, education should be promoted within the physician population. If physicians can model to the individual how to properly use their medication adherence to a schedule is likely to increase.
Adherence to guidelines
National guidelines emphasize that families and healthcare providers should work together to manage asthma, focusing on prevention. According to the guidelines preventive management includes controlling environmental triggers to prevent asthma episodes, promoting regular use of medications, having an asthma action plan and having the physician refer the patient to a specialist when required. Assessing asthma severity from the first visit helps guide treatment. Regular check-ups are important to adjust treatment (Canino et.al., 2022).
Practice policies
Recent studies found that when organizations provided asthma screening reports to doctors, improved access and continuity of care, and trained staff in cultural competence, patients had better asthma outcomes and rated their care higher. These policies helped patients use their medications correctly and they showed better physical health at follow-up (Canino et.al., 2022). When practice policies are put into place in the institution, it can decrease bias and stereotyping by providing a framework for physicians to follow.
While the institution plays a vastly important role in diagnosis and treatment, we can see how the other levels influence it. Is the individual advocating for their own care and willing and able to manage their asthma? On the society level, is access to care readily accessible and affordable? It is easy to forget that there are influences outside of the healthcare system because we are so engrained in the treatment and care. It is important to remember that each person is an individual with a unique experience. Beyond the institution, is legislation. By design, out of reach of individuals but something that affects every other level directly as these are the decision makers at the highest level of pharma, insurance and government.
Legislative
Legislation and policy in agencies such as the government and insurance companies can have a significant effect on people with asthma. These include:
Access to care
An individual’s access to care can alter the outcomes of an asthma diagnosis. Difficulty accessing a family doctor leads to difficulty in obtaining a specialist referral which can lead to little or no preventative care or active treatment. If a person has a family doctor and is referred to a specialist, the wait times to access the specialist can pose a significant barrier to positive outcomes.
Benefit availability & Drug cost
An individual’s access to drug coverage benefits has a significant effect on medication use. If an individual has access to benefits, they are more likely to get the prescription filled. If there is no access to benefits and a person has to pay for the treatment out of pocket, it becomes a significant barrier to treatment. Increasing the accessibility to benefits that assist people in paying for the medications would see increased adherence to a treatment plan (Asamoah-Boaheng et.al., 2022).
Environmental Controls
In the broadest strokes possible and at the top of the policy ladder are environmental policies. Those that enable the population to have clean air to breath and clean water to drink. Government imposes levies on businesses and household to reduce their carbon outputs. They can promote clean living and encourage the population to reduce their impact on the earth. If policy can enable and enact change that would assist in the management of conditions like asthma, each other level of influence would be affected. However, this change cannot be accomplished without the buy in of the individual, society and institution.
Each level of influence—individual, societal, environmental, institutional, and legislative—plays a role in shaping asthma care. As healthcare professionals and advocates, understanding these factors helps us drive positive change and improve positive patient outcomes.
References
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increasing: A population-based study. Allergy, Asthma & Clinical Immunology,
Asamoah-Boaheng, M., Farrell, J., Bonsu, K. O., Oyet, A., & Midodzi, W. K. (2022). Association
between medication adherence and risk of COPD in adult asthma patients: A retrospective cohort study in
Canada. Clinical Epidemiology, 14, 1241–1254. https://doi.org/10.2147/CLEP.S370623
Galea, S. (2015, May 31). The determination of health across the life course and across levels of
influence. Boston University School of Public Health. https://www.bu.edu/sph/news/articles/2015/the-
Institute of Medicine. (2010). Promoting cardiovascular health in the developing world: A critical
challenge to achieve global health. http://www.iom.edu/Reports/2010/Promoting-Cardiovascular-Health-in-the-
Developing-World-A-Critical-Challenge-to-Achieve-Global-Health.aspx
LungSask. (2022). Inhaler resources. https://www.lungsask.ca/lungs/programs-support/inhaler-resources
Stanescu, S., Kirby, S. E., Thomas, M., et al. (2019). A systematic review of psychological, physical health factors, and
quality of life in adult asthma. npj Primary Care Respiratory Medicine, 29(37). https://doi.org/10.1038/s41533-
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