Impact of Therapeutic Education on Asthma Control, Medication Adherence, Knowledge and Quality of Life in Moroccan Adult Asthma Patients

Impact of Therapeutic Education on Asthma Control, Medication Adherence, Knowledge and Quality of Life in Moroccan Adult Asthma Patients

The Open Public Health Journal 26 Jul 2023 RESEARCH ARTICLE DOI: 10.2174/18749445-v16-230714-2023-121



Asthma is still a partially or not controlled disease in most cases despite the availability of effective treatment options. It is among the most common causes of annual intensive care unit visits and physician admissions. Therapeutic patient education can be an effective strategy to improve patients' knowledge to understand their disease and develop coping strategies. This will eventually lead to symptom control and improvement in treatment compliance and quality of life.


This study aimed to assess the effects of a structured educational intervention on asthma control, medication compliance, asthma knowledge, and quality of life of adult asthma patients


This study included 211 adult asthma patients over 18. The Asthma Control Test (ACT), the eight-item Morisky Medication Adherence Scale (MMAS-8), the mini Asthma Quality Life Questionnaire (mini-AQLQ), and the Adult Patient Asthma Knowledge Questionnaire (AP-AKQ) were completed both before and after the three-month educational intervention. Comparison of pre-and post-education outcomes was performed by the Wilcoxon test for quantitative variables with non-normal distribution as well as qualitative variables.


Three months after the educational intervention, there was a significant improvement (p<0.001) in ACT score from (18.00 (15.00-21.00) to 20.00 (19.00-21.00), mini-AQLQ score from 5.04 (4.44-5.72) to 5.75. (5.25-6.35), MMAS-8 score from 6.00(3.00 - 8.00) to 8.00(6.00 - 8.00) and AP-AKQ score from 39.00(36.00-43.00) to 51.00(48.00-52.00). Also, the proportion of patients with well-controlled asthma, good compliance, and higher quality of life increased significantly.


Our results suggest that a structured educational intervention, with content based on patients' perceived needs, may provide benefits regarding disease control, medication adherence, quality of life, and knowledge in asthma patients.

Keywords: Patient education, Asthma, Adult asthma patients, Medication compliance, Asthma control, Quality of life, Asthma knowledge.


Asthma is a common chronic respiratory condition that affects approximately 300 million people worldwide, with a mortality of around 250,000 per year. Over the past decade, the goals of asthma management have shifted to focus on achieving and keeping good asthma control and reducing future risks, such as decreased lung function, asthma exacerbations, hospitalizations, adverse effects of treatment, and death [1]. Despite the availability of highly effective inhaled medications, the disease remains insufficiently controlled in a large proportion of patients. This is partly because these therapies are only effective when used correctly. 56% of asthmatics admitted not taking their controller medications daily [2] with prolonged interruptions over the long term. It's the same for inhaler handling and the peak flow meters using [3]. As a result, poor adherence leads to poor health outcomes, decreases patient well-being, and increases healthcare costs [4, 5]. However, asthma treatment includes non-pharmacological components, namely environmental control and sports practice. The goal of asthma treatment is to achieve optimal disease control: to limit chronic symptoms, especially at night, to allow normal physical activity, to prevent exacerbations and limit visits to the emergency room and hospitalizations, to maintain normal or near-normal lung function (>80% of the theoretical value) [6]. Moreover, asthma is often associated with a number of organic or functional comorbidities that worsen disease control and contribute to impaired patient quality of life (QOL) [7, 8].

The strategies for optimal asthma control include reduction of environmental risk factor exposure, assessment of asthma severity, appropriate treatment according to severity level, regular symptom and lung function monitoring, with adjustment of treatment intensity if necessary, and finally, patient education and counselling [1].

Many previous studies recommended therapeutic patient education (TPE) and self-management training to improve patients' skills and showed that education and information about the disease could help patients improve their asthma control, lung function, and QOL [9-13]. Therapeutic patient education is a structured, ongoing process integrated into care and centered on the patient, comprising organized activities, including psychosocial support, designed to make patients aware and informed about their illness and about hospital care, organization and procedures, and health and illness-related behaviours [14]. It aims to enable patients and their families to acquire and maintain the self-care and coping skills necessary to manage their lives with a chronic illness [15].

Thus, asthma education is considered by current asthma guidelines and strategies as an important component of bronchial asthma management and is recommended with the highest level of evidence [1]. It can help patients improve their asthma control and lung function, reduce the frequency of asthma attacks and nocturnal respiratory disorders, decrease the number of hospitalizations, emergency room visits, unscheduled medical visits and days of absence from school or work and eventually enhance the asthma patient's quality of life [16].

The purpose of this study was to investigate the effect of a structured TPE program on asthma control, medication adherence, knowledge, and QOL in adult asthma patients.


2.1. Study Design

We conducted a quasi-experimental study among 220 adult asthma patients consulting at the University Hospital of Fez. The study was performed in three phases (Fig. 1). The first phase included patient recruitment and baseline data collection. It lasted four months (March to May 2022). In the second phase, which lasted two months (June-July 2022), educational sessions were planned and implemented. Three months later, the third phase focused on a post educational intervention evaluation through data collection using the same instruments.

2.2. Patients and Sampling

The minimum sample size required was estimated at 156 participants by G*Power software [17], to provide the effect size of 0.2 in ACT score change calculated from a pilot study in which the ACT score after the educational intervention increased from 19.4±14.1 to 20.4±2.8. A study power of 80% was set, with a 2-sided significance level of 0.05. Afterward, it was considered that 15% of the participants could withdraw from the study, so the final sample size required was 180.

Finally, we enrolled 220 adult patients with asthma who were at least 18 years old and whose asthma had been confirmed by functional and clinical investigation for at least six months. Patients with disabling or pulmonary pathologies other than asthma and those with language barriers were excluded. Nine patients withdrew before the educational intervention. Only 211 patients participated in the educational sessions and completed the evaluative phase.

2.3. Data Collection Tools

2.2.1. Asthma Control Measurement

The Arabic version of Asthma Control Test (ACT) was used to assess asthma control. The internal consistency reliability was Cronbach's Alpha = 0.92 [18] (for our population Cronbach's Alpha = 0.918) . It is a five-question questionnaire with a 5-point scale ranging from 1 (reporting the respective symptom all or very frequently) to 5. (never reporting the respective symptom). The total ACT score ranges from 5 to 25. An ACT score of 15 indicates uncontrolled asthma, a score of 15 to 19 implies partially controlled asthma, and a score of 20 to 25 indicates well-controlled asthma [19].

2.3.2. Medication Compliance Measurement

Compliance was assessed using the Arabic version of the eight-item Morisky Medication Adherence Scale validated by Ashur et al. [20] and successfully used in several studies on Arab populations [21]. Our asthma patients' reliability and validity showed excellent psychometric properties (Cronbach's Alpha = 0.886). Each answer has a defined value. Adding the values for each question yields a score between 0 and 8. A value = 8 means good compliance. A score between 6 and 7 means average compliance. A value < 6 signifies poor compliance [22-24].

2.3.3. Knowledge Assessment

Asthma knowledge was assessed by the 54-item Adult Patient Knowledge Questionnaire (AP-AKQ), which consists of four sections: “Pathophysiology of asthma: 13 items”; “Triggers: 15 items”; “Diagnosis and management: 19 items”; and “Asthma treatment: 7 items”. It was developed by experts in the field after consulting 18 surveys and the GINA documents on asthma knowledge that every patient should have [25]. A reliability assessment of the Arabic version revealed an acceptable Cronbach's Alpha (0.762). Content validity was attested by a team of experts, including a psychologist, a pulmonologist and an expert in educational sciences.

The scores were considered dichotomous “correct/incorrect answer”, a “don't know” answer was considered incorrect. An answer key was used to score the questionnaire. A score of 1 was assigned to each correct answer and a score of 0 to each incorrect answer. The total score ranged from 0 to 54 [26].

2.3.4. Quality of Life Assessment

The mini-AQLQ measured QOL validated Arabic version for adult patients with 15 items [27, 28]. The reliability tested in our patients was very satisfactory, with a Cronbach's alpha score equal to 0.915. The survey is divided into four domains: symptoms (5 items), activity limitation (4 items), emotional function (3 items), and environmental stimuli (3 items). Patients respond to each item on a seven-point scale, and results are reported as the mean score of all items (1: extremely impaired, to 7: no impairment). Quality of life was considered good when the overall score is ≥ 6, average between 4 and 6 and poor below 4 [29].

2.4. The Educational Intervention

The educational content was developed in response to the patient’s expressed needs. The main components of the educational program were: disease characteristics, symptoms, causes, complications, inhalation technique, the action of medications and their potential side effects, the difference between rescue and control medications, dosing regimen, goals of asthma treatment, improving compliance, use of peak flow meter, triggers and their avoidance, recognition, and action in case of asthma attack, smoking cessation, general recommendations on nutrition, physical activity, sleep, and vaccination. Furthermore, patients were given a hands-on demonstration and training in inhalation technique, inhaler cleaning, and storage. All participants received two-hour group sessions (10-12 patients) at 2-week intervals.

Fig. (1). Flow chart of study.

The program was based on an interventional educational framework tailored to the patient's characteristics and the study's theoretical framework: the Reasoned Action Approach (RAA). For this purpose, transformative learning, an intervention framework based on adult learning theory, was chosen. It is a learner-centered approach to gaining confidence in new roles and relationships [30]. Furthermore, educational programs based on this theory have yielded promising results in preventing unhealthy behaviors [31, 32].

2.5. Statistical Data

Data were analyzed using IBM SPSS statistics (version 25) software. Descriptive analysis included frequency and percentage for categorical variables. Based on the normality assumption, the continuous variables were described by a mean ± standard deviation or by a median with an interquartile range. Comparison of pre-and post-education outcomes was performed by the Wilcoxon test for quantitative variables with non-normal distribution and qualitative variables. The normality of continuous variables was verified by Kolmogorov-Smirnov. P-values < 0.05 were considered significant.

2.6. Ethical Considerations

The study was approved by the local ethics committee under number 15/2022. Before the investigation, each participant signed a written informed consent to participate in the study. The informed consent contained detailed information about the purpose and relevance of the study so that participants could make an informed choice about whether to participate or withdraw at any time if they wished. Also, the following considerations were guaranteed: voluntary participation; anonymity; confidentiality; and protection from any harm.


The survey included 211 patients, and the primary outcome was asthma control (using the ACT). Other endpoints were medication compliance, knowledge, and quality of life. Two hundred and eleven patients completed pre- and post-education questionnaires and participated in educational sessions.

Patients mean age was 48.67± 15.36 years (Table 1). 72.04% were women, 72.04% were married, half (50.71%) were not attending school, and 76.78% lived in urban areas. Regarding smoking status, 67.77% were non-smokers. The median years with asthma was 7.00 (3.00 -1.00). Only 25.59% were covered by health insurance. The detailed demographic profile of the participants can be seen in Table 1.

The primary outcome was asthma control (using ACT). The proportion of patients with well-controlled asthma increased significantly from 39.81% to 62.56% after three months of the educational intervention, while the proportion of patients with uncontrolled asthma decreased significantly from 25.12% to 1.89% (p ˂0.001). The median ACT score increased from 18.00 (15.00-21.00) to 20.00 (19.00-21.00) (p ˂0.001) (Table 2).

Table 1.
Sociodemographic characteristics of patients.
- Categories Effective (n=211) Percentage (%) Mean ±SD
Gender Femal 152 72.04 -
Male 59 27.96 -
Age - - - 48.67 ± 15.36
Duration of asthma - - - 7.00 (3.00 -1.00) *
BMI - - - 26.92 ± 4.47
Marital status Single 35 16.59 -
Married 152 72.04 -
Divorced 8 3.79 -
Widowed 16 7.58 -
Educational level No schooling 107 50.71 -
Primary 51 24.17 -
Secondary 38 18.01 -
Higher 15 7.11 -
Residence Urbain 162 76.78 -
Rural 49 23.22 -
Coverage by health insurance Yes 54 25.59 -
No 157 74.41 -
Smoking status Ex-smoker 30 14.22 -
Non-smoker 143 67.77 -
Passive smoker 37 17.54 -
Active smoker 1 0.47 -
Note: BMI: body masse index
*: median (interquartile range)
Table 2.
Effect of TPE on asthma control, medication compliance, asthma knowledge, and participants' quality of life after three months.
Variable Responses Baseline 3-month Visit P-value
Asthma control ACT score, median
(Interquartile range)
18.00 (15.00-21.00) 20.00 (19.00-21.00) ˂0,001
Well-controlled, n (%) 84 (39.81) 132 (62.56) ˂0,001
Partially controlled, n (%) 74 (35.07) 75 (35.55)
Uncontrolled, n(%) 53 (25.12) 4 (1.89)
Asthma knowledge AP-AKQ Score, median
(Interquartile range)
39.00 (36.00-43.00) 51.00 (48.00-52.00) ˂0,001
Medication adherence MMAS-8 score, median (interquartile range) 6.00 (3.00 - 8.00) 8.00 (6.00 - 8.00) ˂0,001
High adherence, n (%) 91 (43.13) 133 (63.03) ˂0,001
Medium adherence, n (%) 29 (13.74) 49 (23.22)
Low adherence, n (%) 91 (43.13) 29 (13,75)
Quality of life Mini-AQLQ score, median (interquartile rang) 5.04 (4.44-5.72) 5.75 (5.25-6.35) ˂0,001
Good QOL, n(%) 38 (18.01) 95 (45.02) ˂0,001
Average QOL, n(%) 148 (70.14) 113 (53.56)
Low QOL, n(%) 25 (11.85) 3 (1.42)
Note: Mini-AQLQ: mini asthma quality of life questionnaire
ACT: asthma control test
AP-AKQ-AP: adult patient asthma knowledge questionnaire
MMAS-8: The eight-item Morisky Medication Adherence Scal

Other endpoints were medication adherence, knowledge, and quality of life. Regarding compliance, The Morisky score improved significantly (p˂0.001) from 6.00(3.00 - 8.00) to 8.00(6.00 - 8.00), and the percentage of patients with good compliance increased from 43.13% to 63.03%, while one of patients with poor compliance decreased from 43.13% to 13.75% (p˂0.001).

Three months after TPE, the Mini-AQLQ score for quality of life improved significantly (p˂0.001) from 5.04 (4.44-5.72) to 5.75. (5.25-6.35). Similarly, the proportion of patients with a good quality of life increased from 18.01% to 45.02%, while those with a poor quality of life decreased from 11.85 to 1.42%.

Finally, there was a significant improvement in the score knowledge, which significantly improved from 38.85±5.37 to 50.08 ± 2.62 after education (p˂0.001).


Therapeutic patient education is a nonpharmacological intervention that assists patients and their families in developing or maintaining the skills required for managing their chronic disease. Several previous studies back up the hypothesis that therapeutic patient education is critical for improving asthma patient knowledge, disease self-management, and attack prevention [13, 33].

There was no control group in our study. We used pre-education data as a control and compared it to post-education data. We educated our patients on the pathophysiology of asthma, its causes, complications, inhalation technique, medication action and potential side effects, triggers, and their avoidance, warning signs of attack, attack management, and healthy lifestyle rules.

This study was therefore conducted to examine the effect of a structured asthma TPE program based on participants' perceived needs on asthma control and asthma knowledge and quality of life in adult asthma patients. We postulated that TPE would improve asthma knowledge and, as a result, disease control and quality of life in Moroccan adult asthma patients. And according to our findings, we confirmed this hypothesis.

We have proved the importance of an educational intervention over a short period (3 months). This enhanced the participants' asthma knowledge, disease control, medication compliance, and quality of life. This improvement occurred even without changing the patients' previous pharmacological treatment, thus showing the importance of the educational approach in asthma management. The observed improvement in asthma control, medication compliance, and quality of life can be attributed to an increase in patients' knowledge as a result of an educational intervention that covered multiple aspects of the condition.

After asthma education, there was a highly significant improvement in the level of asthma control (the primary goal of long-term management) in our study. This was consistent with several studies [11, 12, 16, 34, 35] that showed significant improvement in asthma control after asthma education in adults and children using the Asthma Control Test (ACT). Other studies, however, did not show a significant effect of asthma education on asthma control as assessed by the number of symptom-free days, daily peak flow measurement, or ACT score [13, 36-38].

In terms of medication adherence, our results showed an improvement in its score with a significant increase in the proportion of participants with good adherence. Similarly, recent reviews have shown a positive impact of pharmacist-led interventions on inhaler technique and medication adherence in adult asthma patients [39-41]. Also, many studies have reported improved compliance after educational interventions with adult and pediatric asthma patients [37, 42, 43]. In Turkey, nevertheless, a randomized controlled trial did not reveal a statistically significant difference between the Morisky Medication Adherence Scale scores in the intervention and control groups in medication compliance [44]. Medication compliance in asthma patients decreases with age, particularly from adolescence onwards. There are several reasons for poor compliance: the complexity of the treatments, difficulties in using the inhalers, lack of understanding or perception of their benefits and fear of side effects. Hence, poor compliance is associated with risks of unnecessary therapeutic escalation and worsening of asthma, with more exacerbations, increased school absenteeism, deterioration of quality of life, and even excess mortality. The management of non-compliance implies a good caregiver/asthmatics relationship, better provider training and personalized patient education [45].

Regarding QOL, it’s a very broad concept influenced in a complex way by the individual's physical health, psychological state, level of independence, social relationships and relationship to the essential elements of the environment. For an asthmatic, a good quality of life means not being hampered by the disease and being able to carry out activities and projects without being hampered by respiratory symptoms. A good QOL for an asthmatic also means not having to live with the constant fear of an attack, not being woken up at night by a cough and the risk of visiting the emergency room.The impact of TPE on the quality of life of asthma patients has been assessed in several studies. In some of them, there was no difference in the quality of life, such as the one conducted by Perry et al. among asthmatic children [37]. Whereas in others, there was an improvement in QOL scores after educational interventions [46, 47] using asthma-specific questionnaires. Recently, Felix et al. study assessed the quality of life change measured by the AQLQ questionnaire after education. There was an improvement in the intervention group after four and eight weeks (p = 0.005) [13].

Finally,a recent survey in Morocco found that the five dimensions of quality of life measured by the EUROQOL questionnaire were significantly satisfactory after three months of educational intervention [34]. The 5-dimensional EUROQOL questionnaire is not specific for asthma but rather generic for all diseases [48].

Further, effective asthma management requires that patients should have specific knowledge in order to control their asthma. Accordingly, patients should recognize: the pathophysiology of asthma and the lung changes underlying the disease, the role of different medications used in the treatment of asthma, self-monitoring and the use of inhalers and spacer devices, environmental controls (asthma triggers), and the signs and symptoms of uncontrolled asthma that may indicate an exacerbation [49].

For asthma knowledge, a very significant improvement in the score was revealed by our study. A better knowledge of asthma will assist patients in understanding the necessity of maintaining their disease under control [39]. Similarly, other studies among adult and teenage asthma patients have shown similar results [10, 50, 51].


Our findings suggest that an educational intervention may improve asthma patients' disease control, medication adherence, quality of life, and knowledge. However, these findings must be interpreted in light of the study's limitations. First, there was no control group in the study. Second, patients agreed to participate in the study voluntarily, and it is to be expected that patients will be highly motivated to participate in self-care education, resulting in higher outcome estimates.


Our study had no control group, but the pre-PET program results were used as a control. Furthermore, the follow-up time after the educational intervention was limited to three months, whereas behavior change is a long-term process.


ACT = The Asthma Control Test
MMAS-8 = The Eight-item Morisky Medication Adherence Scale
Mini-AQLQ = The Mini Asthma Quality Life Questionnaire
AP-AKQ = The Adult Patient Asthma Knowledge Questionnaire
RAA = The Reasoned Action Approach
QOL = Quality of life
TPE = Therapeutic Patient Education
BMI = Body Mass Index


The study was approved by the local ethics committee under number 15/2022. Before the investigation, each participant signed a written informed consent to participate in the study. The informed consent contained detailed information about the purpose and relevance of the study so that participants could make an informed choice about whether to participate or withdraw at any time. Also, the following considerations were guaranteed: voluntary participation; anonymity; confidentiality; and protection from any harm.


No animals were used in this research. All procedures performed in studies involving human participants were by the ethical standards of institutional and/or research committees and with the 1975 Declaration of Helsinki, as revised in 2013.


Informed consent was obtained from all participants.


The authors confirm that the data supporting the findings of this study are available within the article.




The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


We would like to thank all the patients who participated in the study. We also thank all the health professionals of the pneumology department of the CHU Hassan II of Fez for their support throughout this study.


Global Initiative for Asthma. Global strategy for asthma management and prevention. 2022. Available From:
Raherison C, Mayran P, Jeziorski A, Deccache A, Didier A. Patient asthmatique : Contrôle, ressenti et observance. Résultats français de l’enquête REALISE™. Rev Mal Respir 2017; 34(1): 19-28.
Laforest L, Belhassen M, Devouassoux G, Didier A, Letrilliart L, Van Ganse É. L’adhésion thérapeutique dans l’asthme en France : Revue générale. Rev Mal Respir 2017; 34(3): 194-222.
Dekhuijzen R, Lavorini F, Usmani OS, van Boven JFM. Addressing the Impact and unmet needs of nonadherence in asthma and chronic obstructive pulmonary disease: Where do we go from here? J Allergy Clin Immunol Pract 2018; 6(3): 785-93.
Sabaté E, Ed. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization 2003.
Taillé C. Asthme : Actualités sur les nouveaux traitements de l’asthme sévère. Revue des Maladies Respiratoires Actualités 2017; 9(3): 428-32.
Global Initiative for Asthma. Diagnosis and Management of Difficult-to-treat & Severe Asthma. 2019. Available From:
Heffler E, Crimi C, Mancuso S, et al. Misdiagnosis of asthma and COPD and underuse of spirometry in primary care unselected patients. Respir Med 2018; 142: 48-52.
Clark NM, Griffiths C, Keteyian SR, Partridge MR. Educational and behavioral interventions for asthma: Who achieves which outcomes? A systematic review. J Asthma Allergy 2010; 3: 187-97.
Elbanna RMH, Sileem AE, Bahgat SM, Ibrahem GA. Effect of bronchial asthma education program on asthma control among adults at Mansoura district. Egypt J Chest Dis Tuberc 2017; 66(4): 561-9.
Schuermans D, Hanon S, Wauters I, Verbanck S, Vandevoorde J, Vanderhelst E. Impact of a single 10 min education session on asthma control as measured by ACT. Respir Med 2018; 143: 14-7.
Zeng YQ, Au DH, Cai S, et al. Effect of a patient education intervention on asthma control and patient-doctor relationship. Chin Med J 2018; 131(9): 1110-2.
Felix SN, Agondi RC, Aun MV, et al. Clinical, functional and inflammatory evaluation in asthmatic patients after a simple short-term educational program: A randomized trial. Sci Rep 2021; 11(1): 18267.
World Health Organization.Regional Office for Europe.. Therapeutic patient education: Continuing education programmes for health care providers in the field of prevention of chronic diseases: Report of a WHO working group. 1998. Available From:
Organisation mondiale de la Santé. Bureau régional de l’Europe. Education thérapeutique du patient : programmes de formation continue pour professionnels de soins dans le domaine de la prévention des maladies chroniques : Recommandations d’un groupe de travail de l’O.M.S. 1998. Available From:
Paoletti G, Keber E, Heffler E, et al. Effect of an educational intervention delivered by pharmacists on adherence to treatment, disease control and lung function in patients with asthma. Respir Med 2020; 174: 106199.
Kang H. Sample size determination and power analysis using the G*Power software. J Educ Eval Health Prof 2021; 18: 17.
Lababidi H, Hijaoui A, Zarzour M. Validation of the Arabic version of the asthma control test. Ann Thorac Med 2008; 3(2): 44-7.
Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test. A survey for assessing asthma control. J Allergy Clin Immunol 2004; 113(1): 59-65.
Ashur ST, Shamsuddin K, Shah SA, Bosseri S, Morisky DE. Reliability and known-group validity of the Arabic version of the 8-item Morisky Medication Adherence Scale among type 2 diabetes mellitus patients. East Mediterr Health J 2015; 21(10): 722-8.
Khayyat SM, Khayyat SMS, Hyat Alhazmi RS, Mohamed MMA, Abdul Hadi M. Predictors of medication adherence and blood pressure control among Saudi Hypertensive Patients Attending Primary Care Clinics: A cross-sectional study. PLoS One 2017; 12(1): e0171255.
Bress AP, Bellows BK, King JB, et al. Cost-effectiveness of intensive versus standard blood-pressure control. N Engl J Med 2017; 377(8): 745-55.
Berlowitz DR, Foy CG, Kazis LE, et al. Effect of intensive blood-pressure treatment on patient-reported outcomes. N Engl J Med 2017; 377(8): 733-44.
Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens 2008; 10(5): 348-54.
Beaurivage D, Boulay ME, Frenette E, Boulet LP. Développement et validation d’outils de mesure des connaissances du patient : Le modèle du Questionnaire de connaissances sur l’asthme destiné aux patients adultes (QCA-PA). Rev Mal Respir 2016; 33(5): 350-64.
Beaurivage D, Boulet LP, Foster JM, Gibson PG, McDonald VM. Validation of the patient-completed asthma knowledge questionnaire (PAKQ). J Asthma 2018; 55(2): 169-79.
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.
Juniper EF, Wisniewski ME, Cox FM, Emmett AH, Nielsen KE, O’Byrne PM. Relationship between quality of life and clinical status in asthma: A factor analysis. Eur Respir J 2004; 23(2): 287-91.
Sundh J, Wireklint P, Hasselgren M, et al. Health-related quality of life in asthma patients - A comparison of two cohorts from 2005 and 2015. Respir Med 2017; 132: 154-60.
Tsimane TA, Downing C. A model to facilitate transformative learning in nursing education. Int J Nurs Sci 2020; 7(3): 269-76.
Shakibazadeh E, Sabouri M, Mohebbi B, Tol A, Yaseri M, Babaee S. Effectiveness of an educational intervention using theory of planned behavior on health care empowerment among married reproductive-age women: A randomized controlled trial. J Educ Health Promot 2020; 9(1): 293.
Shahmohamadi F, Hoseini M, Matbouei M, et al. The effect of educational intervention based on the theory of planned behavior aimed at mothers on osteoporosis prevention behaviors in lower secondary school female students. J Educ Health Promot 2022; 11: 15.
Martínez-González CL, Camargo-Fajardo MCC, Segura-Medina P, Quezada-Bolaños P. Therapeutic patient education with learning objects improves asthma control in Mexican children. J Med Syst 2020; 44(4): 79.
Bougadoum M, Ait Batahar S, Amro L. Impact d’une intervention éducative de l’asthmatique sur la qualité de vie, l’observance thérapeutique et le contrôle de la maladie. Revue des Maladies Respiratoires Actualités 2022; 14(1): 80.
Lesourd B, Juchet A, Broue-Chabbert A, et al. At the School for Asthma ... Evaluation of a therapeutic education program. Rev Fr Allergol 2014; 54: 438-50.
Praena-Crespo M, Aquino-Llinares N, Fernández-Truan JC, Castro-Gómez L, Segovia-Ferrera C. Asthma education taught by physical education teachers at grade schools: A randomised cluster trial. Allergol Immunopathol 2017; 45(4): 375-86.
Perry TT, Halterman JS, Brown RH, et al. Results of an asthma education program delivered via telemedicine in rural schools. Ann Allergy Asthma Immunol 2018; 120(4): 401-8.
Maricoto T, Madanelo S, Rodrigues L, et al. Educational interventions to improve inhaler techniques and their impact on asthma and COPD control: A pilot effectiveness-implementation trial. J Bras Pneumol 2016; 42(6): 440-3.
Jia X, Zhou S, Luo D, Zhao X, Zhou Y, Cui Y. Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: A systematic review and meta-analysis. J Clin Pharm Ther 2020; 45(5): 904-17.
Mes MA, Katzer CB, Wileman V, Chan AHY, Horne R, Taylor SJC. Pharmacist-led adherence support in general practice: A qualitative interview study of adults with asthma. BMJ Open 2019; 9(11): e032084.
Mes MA, Katzer CB, Chan AHY, Wileman V, Taylor SJC, Horne R. Pharmacists and medication adherence in asthma: A systematic review and meta-analysis. Eur Respir J 2018; 52(2): 1800485.
Kovačević M, Ćulafić M, Jovanović M, Vučićević K, Kovačević SV, Miljković B. Impact of community pharmacists’ interventions on asthma self-management care. Res Social Adm Pharm 2018; 14(6): 603-11.
Rice JL, Matlack KM, Simmons MD, et al. LEAP: A randomized–controlled trial of a lay-educator inpatient asthma education program. Patient Educ Couns 2015; 98(12): 1585-91.
Şanlıtürk D, Ayaz-Alkaya S. The effect of a theory of planned behavior education program on asthma control and medication adherence: A randomized controlled trial. J Allergy Clin Immunol Pract 2021; 9(9): 3371-9.
Jébrak G, Houdouin V, Terrioux P, Lambert N, Maitre B, Ruppert AM. [Therapeutic adherence among asthma patients: Variations according to age groups. How can it be improved? The potential contributions of new technologies]. Rev Mal Respir 2022; 39(5): 442-54.
Zhang X. Positive change in asthma control using therapeutic patient education in severe uncontrolled asthma: A one-year prospective study. Asthma Res Pract 2021; 7(1): 10.
Magar Y, Vervloet D, Steenhouwer F, et al. Assessment of a therapeutic education programme for asthma patients: “Un souffle nouveau”. Patient Educ Couns 2005; 58(1): 41-6.
de Pouvourville G, Andrade L, Touboul C, Ludwig K, Oppe M, Goni JR. Valorisation des états de santé du questionnaire de qualité de vie Euroqol-5D-5L. Rev Epidemiol Sante Publique 2020; 68: S105.
Hasan S, Mahameed S. Assessing patient knowledge of asthma using a newly validated tool. Value Health Reg Issues 2020; 22: 108-14.
Boulet LP, Boulay MÈ, Gauthier G, et al. Benefits of an asthma education program provided at primary care sites on asthma outcomes. Respir Med 2015; 109(8): 991-1000.
Mammen JR, Rhee H, Atis S, Grape A. Changes in asthma self-management knowledge in inner city adolescents following developmentally sensitive self-management training. Patient Educ Couns 2018; 101(4): 687-95.