Rosemary L. Hoffmann; Wesley M. Rohrer III; Jeannette E. South-Paul; Ray Burdett; Valerie J. M. Watzlaf

J Community Health.  2008;33(6):374-383.  ©2008 Springer
Springer Science+Business Media

Abstract and Introduction

Abstract

This cross sectional descriptive study sought to identify perceived barriers to follow-up care for adult asthmatics who are followed in two community health care facilities. A second purpose of the study was to determine the effect of any barriers to Health Related Quality of Life (HRQL) and compliance in the sample. Thirty-four adults completed a demographic and health status survey, the MiniAQLQ and the EWash Access to Health Care Survey. "Long waiting time in provider's office," "someone had to miss work," "cost of care too much, "and "long wait for an appointment" were the most prevalent perceived barriers in the sample. "Lack of transportation" was significantly associated with study participants who receive health care at one site or who stated the emergency room as their usual place of care. "Someone had to miss work" was significantly correlated with the following variables: employment, a higher annual household income, 1-2 daily medications for asthma, no overnight hospitalizations for asthma and no psychological co-morbidities. A higher reported HQOL was significantly correlated with study participants whose medical care needs were met and found access to local health care services. The only perceived barrier that was significantly correlated with compliance was study participants who "sometimes" had to reschedule an appointment with a health care provider due to "lack of transportation." The present study suggests that strategies designed to decrease the perceived barriers might improve compliance with the treatment regime, thus decreasing costs, absenteeism, and lack of continuity.

Introduction

Asthma is a major public health problem in the United States. According to the 2006 National Health Interview Survey, approximately 11% of adults 18 years of age or older have been diagnosed with asthma and the disease is not limited to age, ethnic origin, or socioeconomic status.^[1] The disease has been associated with familial, infectious, allergenic, socioeconomic, psychosocial, and environmental factors.^[2] Asthma is responsible for approximately 10 million physician office visits, over 100 million days of restricted activity, and total annual costs of over $11 billion.^[3]

The impact of socioeconomic status on health care and use of medical services has been studied with a variety of chronic disease states including asthma.^[4-7] Additional studies have shown that insurance coverage, in and of itself, do not guarantee use of timely and appropriate medical care.^[8-11] Some health system organizational obstacles, other than financial reimbursement, faced by asthma sufferers include difficulty scheduling follow-up appointments, lack of continuity in provider, long waiting times in a health care facility, inconvenient office hours and cultural insensitivity.^[12-18] Some clinician-related barriers to adherence in adults may be staff or physician disinterest and limited time to answer specific questions related to treatment regime.^[12] Finally, economic barriers, besides insurance coverage include insufficient sick leave, child care costs, limited or inadequate transportation to the provider's site of care and out-of-pocket medical expenses, such as medication and treatment co-payments.^{[11,14,17,19]} If organizational, clinician or patient-specific factors are significant barriers, they may result in delays in follow-up care and adverse health outcomes independent of health insurance.^[20] Since asthma is a chronic disease that can be successfully managed in a community setting, it is important to ascertain the barriers that influence the patient's ability to receive quality health care in the community.

Although the relationship between health related quality of life (HRQL) and asthma has been studied from a treatment regime, little research exists that examine the effects of barriers and/or facilitators on HRQL.^[21-23] Some barriers cited that showed a relationship between HRQL and asthma include health care beliefs ("I do not understand everything I have been told about my disease")^[24] accessibility of provider^[24] and health care utilization.^[25] Other studies have found that consultation with a physician,^[21] follow-up telephone calls,^[22] therapeutic treatments by an allergist^[26] or behavioral interventions that promote self management^[23] have an effect of HRQL. However, little research exists that identifies the barriers and/or facilitators of follow-up asthma care in community and its effect on HRQL. As a result of the chronic nature of the disease, the potential for life-threatening exacerbations, and the burden of day-to-day management, it is imperative that researchers identify those specific barriers that hinder care so that effective interventions and congruent health policies are developed.

The purpose of this study is to determine self reported barriers for follow-up care among adult asthmatic patients receiving care from urban community health care facilities. Two secondary purposes are to determine what effect these barriers have on HRQL and compliance with follow-up health care management.

Methods

Design

This study was a descriptive cross-sectional design. Study participants were recruited who met the following inclusion criteria,: (1) ability to read, speak and comprehend English (needed for instrument completion), (2) attained 18 years of age or older, (3) have been told by a physician or health care provider that they had asthma, (4) show no evidence of cognitive disorders that would interfere with data collection, and (5) utilize one of the two selected urban community health care facilities for routine health care on a regular basis.

Setting

The study was conducted at two outpatient health facilities of the University of Pittsburgh Medical Center (UPMC) Health System. The cross-sectional design allowed for examination of the effects related to differences in socioeconomic status, age, and ethnicity on the outcomes measured.

Tools

Demographic Questionnaire/Health Status Questionnaire

Two investigator developed tools were used to obtain demographic and health status data. Demographic data was obtained from a questionnaire that identified age, gender, employment status (outside the home), socioeconomic status, education, race, marital status, and number of dependents. The Health Status questionnaire asked subjects to identify the number of asthma medications prescribed, number of emergency room visits within the last 12 months, years with asthma, number of community health visits to a primary care provider (PCP) within the last 12 months, identification of physiologic and/or psychologic co-morbidities, and compliance with the treatment regime. The three compliance questions related to difficulty following the prescribed plan of care, frequency of missed medications, and number of cancelled or rescheduled appointments with a healthcare provider.

Mini Asthma Quality of Life Questionnaire (MiniAQLQ)

The MiniAQLQ is an asthma specific, 15 item self-administered questionnaire developed by Juniper, Guyatt, Ferrie, and Griffith.^[27] Scores in four domains; activity limitations, symptoms, emotional function, and exposure to environment stimuli and a summary score, are obtained. Reliability was acceptable for the MiniAQLQ (interclass correlation coefficient = 0.83) and responsiveness was good (P = 0.0007).^[27] Construct validity was strong and criterion validity showed there was no bias (P = 0.61).^[27] Although the tool was developed in Canada, Leidy and Coughlin found that the MiniAQLQ can be a useful outcome measure for clinical trials conducted in the United States.^[28]

Eastern Washington Access to Health Care Consumer Survey 2001

The Eastern Washington Access to Health Care Consumer Survey 2001 (EWash) was developed by Higgs, Bayne and Murphy to assess the perceptions of health care access and satisfaction with health care in the Spokane Washington area.^[29] The original tool consisted of 90 items with scores ranging from "not at all" (0) to "totally" (100) for each item. Subscales of the instrument include the perceived degree to which the need for services are met in relation to medical, dental, and mental health services. Cronbach alpha reliability coefficients ranged from 0.72 to 0.96 for subscales.^[29] Since certain subscales on the EWash did not pertain to the present study, the tool was modified with permission from the developer. The EWash for this study consist of the following subscales: medical care need, prescription drug needs, satisfaction with care, health insurance, health insurance coverage, health care costs not covered, local availability of services, barriers to obtaining health care, concerns related to health care, health of the members of your household, and sources of health care and health information for a total of 10 subscales. There are 66 total questions. Responses are recorded using either a five or six point Likert scale. The final two open ended questions relate to health information for a total of 68 questions in the tool.

Sample

After IRB approval was obtained, approximately 85 study packets were distributed between the two sites. Thirty-five packets were returned. One participant did not meet the study criteria and was eliminated from data analysis. The remaining 34 packets constituted the study sample. This represented a 41% return rate. Mean response rates to mailed surveys published in medical journals has been cited at 59% ± 20% (median 59%).^[30] All but three of the study participants received their health care from either site. These three study participants saw information related to the study in the waiting room while family members were seen at the facility. Staff members distributed a study packet to these participants. Since the number was small and met all study criteria except receiving health care at one of the two outpatient facilities, they were included in data analysis. Missing data was minimal and noted in the discussion. All data was analyzed using both parametric and non parametric statistical programs. Data for all research questions is reported using parametric statistics since no difference was found with comparable non parametric programs.

Results

Ninety-four percent (94%) of the sample was female. In 2004, Allegheny County reported the percentage of women with asthma as 11% compared to 7% for men.^[31] In terms of employment, 36.2% reported full-time employment which comprised the largest portion of the sample. Forty-seven percent of the sample earned less than $19,000 annually. The lowest income bracket exceeds the U.S. Census report in Allegheny County of 22% below $19,999.^[32] Even though these numbers exceed the U.S. Census report, only 10 subjects (29.4%) perceived a great deal of difficulty paying for basic needs. Asthma is not the only medical condition that warranted physician's care for many sample participants. Fifty-eight percent (58%) of the sample reported a variety of other co-morbidities including hypertension, diabetes, and high cholesterol. Depression was the most common psychological condition reported by the sample ( Table 1 ).

One subscale on the EWASH asked subject participants whether or not during the last year any of the following health care barriers were experienced by a member of their household. There were 10 listed barriers. Agreement with the barriers was analyzed using a Likert scale. Scale answers were "N/A" "Strongly disagree," "Disagree," "Neutral," "Agree" and "Strongly agree" using a 5 point Likert scale with 1 = strongly disagree and 5 representing "strongly agree." N/A answers were not included in the data analysis. A higher mean score indicated agreement that a member in the respondent's household experienced the barrier within the past year. The sample participants perceived "long waiting time in the provider's office" as the greatest barrier with a mean score of 3.1, which falls between "neutral" and "agree" on the Likert scale. Three study participants answered "N/A" for this barrier. The lowest mean score of 2.23 was recorded for the barrier "did not know where to go for services". Eight study participants marked "N/A" for this barrier.

"Could not be seen by a provider during an emergency" was a barrier for which 67.8% of the study participants either "strongly disagreed" or "disagreed." Twelve study participants, or 46.2%, perceived agreement with the barrier "someone had to miss work." There were eight study participants who selected "N/A" for this statement. Consequently, mean scores were derived for an n = 28. The average mean for all barriers was 2.70, which falls between "disagree" and "neutral" on the Likert scale. Means for the 10 potential barriers are reported in Table 2 .

Table 3 identifies the significant relationships between perceived barriers and selected demographic variables. The barrier "office hours not convenient" was perceived as a significant barrier for white study participants but not for non-white respondents (t = 2.30 P = 0.02). If the study participant worked, they perceived "could not be seen by a provider during an emergency," "cost of care too much," and "someone had to miss work" as barriers to care (P = 0.03, P = 0.00, and P = 0.04 respectively). One demographic variable that was significantly associated with the barrier "someone had to miss work" was household income (P = 0.00). Consequently, the higher the income reported, the more study participants perceive "someone had to miss work" as a barrier. Furthermore, a statistically significant difference was found between overall barriers and study participants who are currently employed (P = 0.00). No statistical significance was found between levels of education, religion, age, or importance of religion and perceived barriers.

Study participants who go to the emergency room for their usual place of asthma care perceive a "lack of transportation" as a barrier (F = 3.96, P = 0.02). No statistical significance was found between number of times study participants saw a primary care provider for asthma within the past 12 months, the number of emergency room visits within the past 12 months and any perceived barriers to health care. Furthermore, study participants who took one or two daily medications for asthma perceived "someone having to miss work" as a barrier (r = −0.51, P = 0.02). A significant relationship was also evident between missing work and the number of times study participants experienced an overnight hospitalization for asthma. Study participants who did not have an overnight stay for asthma perceived "someone missing work" as a greater barrier than participants who had two or more overnight hospitalizations (r = −0.49, P = 0.01). One possible explanation for this finding is that study participants who were more symptomatic as a result of their asthma were not currently working ( Table 4 ).

Treatment for other medical or psychological conditions was each coded as a binomial variable. No statistical significance was found between whether or not study participants were being treated for other medical conditions and individual or overall barriers to health care. Study participants who were not being treated for a psychological condition perceived "someone had to miss work" as a greater barrier to health care than participants currently under treatment by a health care provider for other psychological conditions (t = −4.08, P = 0.00) ( Table 4 ).

Table 5 identifies respective mean scores on the MiniAQLQ. The first 11 question responses were coded 1 through 7. A value of 1 represented "all of the time," 2 "most of the time," 3 "a good bit of the time," 4 "some of the time," 5 "a little bit of the time," 6 "hardly any of the time," and 7 "none of the time." The ranges of mean scores on the MiniAQLQ were 3.35 for "feel bothered by cigarette smoke" to 4.64 "feel bothered by weather or air pollution." Means for the last four questions related to activity limitations ranged from a high of 5.3 for "work related activities (tasks you have to do at work) to 3.85 for "strenuous activities (such as hurrying, exercising, running up stairs, sports)". Except for the question on strenuous activities, the subjects reported only a moderate or less limitation in activities such as walking, housework, climbing steps, talking, playing with peers or visiting friends. Furthermore, the overall mean score signifies a sample of adult asthmatics who perceive their asthma as having either a moderate or some limitation in activity.

Questions on the MiniAQLQ are divided into four domains, plus an overall quality of life score. All study participants, except those who marked "N/A" under the respective barrier were included in data analysis. Study participants who stated agreement with the barrier "cost of care too much" perceived their environmental stimuli quality of life as poor (P = 0.00). In addition, study participants who stated agreement with the barrier "did not know where to go for services" also perceived a lower HRQL in the environmental domain (P = 0.02). The environmental domain refers to stimuli, such as cigarette smoke, dust or air pollution that may trigger asthma exacerbations. Otherwise, the perceived barriers had no significant relationship with the domains of symptoms, activity limitations, emotional functions or overall quality of life ( Table 6 ).

The first compliance question asked study participants to state the level of difficulty experienced following the plan of care prescribed by their health care provider. The options were "very difficult," "somewhat difficult" or "not at all difficult." "Not at all difficult" was chosen by 18 (52.9%) of the study participants. Only 5 (14.7%) study participants believed following the prescribed plan of care was "very difficult." No significant relationship was found between the ten or overall barriers and difficulty following a prescribed plan of care.

ANOVA was used to determine whether or not a relationship existed between any of the ten perceived or overall barriers to the frequency that study participants reported missed taking any medication since their last health care provider's appointment. Once again, no significant relationship was found between any individual barrier or overall barriers and taking medications prescribed by their health care provider for asthma. This is not surprising considering that 20 study participants (58.8%) reported missing a medication not more than once/month or never. Twelve study participants (35.2%) reported they missed taking any medication once a week or greater.

The third question related to compliance asked study participants to rate how often they needed to cancel or reschedule an appointment with their health care provider. Answer options were "frequent," "occasionally," or "never." Within this sample, 20 study participants (58.8%) reported "never" rescheduling or cancelling an appointment. Only two study participants (5.9%) responded "frequently" to missed appointments. To condense response categories and compare missed or cancelled appointments to perceived barriers of care, the category "sometimes" was developed which included any study participant who reported either "frequently" or "occasionally" as a response. A t-test was then employed to analyze the frequency of missed or cancelled appointments to individual or overall barriers of care. Study participants who "sometimes" had to miss or cancel an appointment with their health care provider perceived "lack of transportation" as a greater barrier than study participants who "never" had to reschedule an appointment (P = 0.00). The relationship between overall barriers to care and rescheduled or cancelled appointments was not statistically significant ( Table 7 ).

Discussion

This descriptive cross sectional study examined the effect of barriers on HRQL and compliance in adult asthmatics who are followed in an urban community health care facility. Ambulatory conditions, such as asthma, can be successfully managed in a community health care facility thereby preventing unnecessary hospitalizations. Dependency on emergency rooms for episodic care has been viewed as an inadequate use of resources and poor self-management skills.^[33-35] Studies have shown that reliance on emergency rooms for asthma management can not be explained by simply financial barriers alone.^[36-38]

"Someone had to miss work" has been reported as a barrier with both adult asthmatics and care givers of pediatric patients. One of the major parental impressions of barriers to follow-up care after an asthmatic attack was the requirement that a parent needed to take time off from work.^[37] The only barrier reported higher in the study of 147 participants was finding transportation.^[37] Another study examining utilization and accessibility of primary health care stated work commitments hinder not only access, but specialty consults and home health care.^[39] The indirect costs of missing either full or partial work days for those employed have been reported to average $1731 per person.^[40]

The organizational barriers, such as waiting time and scheduling, are similar to other reported studies. Niefeld and Kasper reported over one-third of elderly Medicare and Medicaid beneficiaries reported greater organizational barriers than financial and geographic.^[41] Some of the organizational barriers included long waiting time, lack of knowledge regarding scheduling appointments and referrals.^[41] Although difficulty communicating with nurses was not a problem, a focus group with chronically ill patients found difficulty scheduling appointments and communicating with a physician during an office visit as barriers to self-management of their disease.^[37] Consequently, Baren et al found that scheduling an appointment increased 30-day follow-up with a primary care provider compared to usual discharge care in adult asthmatics discharged after an exacerbation from an emergency room.^[33]

Finally, transportation barriers are common across the lifespan for asthmatic adults or caregivers of asthma patients. Studies with caregivers of pediatric asthma patients state a lack of transportation, either by personal car or public venues as one of the primary determinants to follow-up care.^[14,37] Furthermore, although parents were able to identify a usual place of care, a lack of transportation required some parents to utilize a hospital clinic or emergency room for after hours or exacerbations.^[9] Similarity, at least one-third non-elderly urban Americans reported a hard time accessing transportation for medical care.^[42] Bender believes inadequate patient adherence to prescribed treatment regimes is multidimensional including clinician-related barriers, such as transportation.^[12]

Age, educational level, religion, importance of religion, and difficulty paying for basic needs was not statistically significant with any perceived barriers in this sample. Similar results by Diette, Krishnan Dominici et al^[43] and Eisner Katz Yelin et al^[44] reported that although older adults with asthma had greater respiratory symptoms and more co-morbidities than younger asthmatics, chronological age was not associated with barriers to health care utilization. Age, not religious heritage, marital status, or social support, may be a barrier in older women, as reported by Barr et al.^[45] They found older women to be undertreated thus leading to nonadherence.^[45] Furthermore, although education was not associated with hospitalizations in older asthmatic patients; it has been cited as a barrier with disadvantaged minority patients.^[18,43] One possible explanation for the lack of significance between educational level and barriers to care may be that 19 (55.7%) of the study participants reported some college or beyond. Only 8.8% of the study participants reported less than a high school education.

Employment and income were significantly associated with the barrier "someone had to miss work." This barrier correlates with the three study participants who took a day off from work in order to drive a family member to the health care facility for primary care. In addition, employment and/or retirement does not equate with adequate health care coverage. Medicare, identified by 24% of the study participants, was the primary health care insurance reimbursement plan. At the time of this study, the Medicare Prescription Drug Plan was not in effect. Consequently, this could be one explanation for the significance of the perceived barrier "cost of care too much." Over seventy percent (70.0%) of the study participants were prescribed two or more daily medications for their asthma.

"Office hours were not convenient" showed statistical significance with white study participants versus other (African American, American Indian, other or mixed ethnicity). Health service use by African Americans (AA) and Caucasians with asthma have shown a higher rate of emergency room visits, rehospitalizations, and fewer visits to a specialist for the AA population.^[25,46] Another explanation for this finding may lie with the employment status of the white study participants. Job requirements may prohibit office visits during the normal business day. Furthermore, three of the 12 white study participants were responsible for transportation of a family member to one of the health care facilities. Office hours in the evening or on weekends may alleviate this barrier.

Study participants who state their usual place of care for asthma as the emergency room perceived "lack of transportation" as a barrier. One of the health care facilities is located on a bus route while the other does not have direct public transportation. The one health care facility not on a public transportation route accepts asthma patients from two subsidized housing facilities. Study participants who reside in one of these housing facilities may not own a car, nor have available transportation via a support system or public access. Although the EWash asked study participants the availability of local services, public transportation was not included in the survey. Lack of transportation has been cited as a barrier for low-income urban poor populations.^{[5,16,18,44,47]} In another study, 75% of respondents who did not own a car cited transportation as a barrier to access a primary health-care facility.^[39]

Four health status characteristics were significantly associated with the barrier "someone had to miss work." The study participants who perceived missing work as a barrier were prescribed one or two medications, had no overnight admissions to the emergency room within the last year, required less visits to a health care facility for asthma or were not diagnosed with a psychological co-morbidity. One explanation for this finding could be the healthy nature of the study participants. It would appear that asthma in this sample is well controlled. Consequently, asthma may not be a hindrance with either activities of daily living or employment. Therefore, a visit to a health care facility may necessitate adjusting their work schedules or seeking assistance from grown children or friends who may be employed.

The only domain of the MiniAQLQ that showed significance with two of the barriers was irritants in the environment that may trigger asthma symptoms such as dust, cigarette smoke or weather/air pollution. Unfortunately, approximately one-fourth of the participants reported the presence of cigarette smoke in their residence. Another factor, household dust, is difficult to control especially in lower socioeconomic areas where half of the study participants reside. This finding correlates with the 35% of the sample reporting difficulty avoiding triggers in their home environment. In addition, over half of the study participants were AA. Studies on HRQL in asthma adults have correlated a lower HRQL with AA and socioeconomic factors, such as income, education, and employment.^{[24,25,48,49]}

Another explanation for the findings is the high proportion of women in the sample. Women have a higher reported incidence of asthma throughout the United States and similar findings have been reported in Allegheny County.^[31] Furthermore, women tend to experience greater impairment of HRQL then men with similar clinical asthma severity.^[50,51] Two other significant findings reported in this sample are the high percentage of never married (41%) and single (29%) study participants. Coupled with the characteristic of a low annual household income may give some credence to the barrier "cost of care too much" as perceived from the study participants and the significant relationship of a lower HRQL in the environmental domain.

Due to the lack of an honest broker for this study, no data on severity of asthma was obtained. As previously discussed, the sample represented asthmatic adults who are not critically hindered from their disease. The results obtained could be a product of the healthy status of study participants or small number in the study. Over 50% of study participants did not find it difficult to follow the plan of care discussed by the health care provider. Adherence to prescribed medications was also not a reported problem in this sample. Twenty study participants (58.8%) reported the incidence of missed medications less than once a month. The lack of significance between barriers and following a plan of care or taking prescribed medications may be explained by the controlled disease state in the sample.

"Lack of transportation" was perceived as a barrier for study participants who "sometimes" had to reschedule or cancel an appointment with a health care provider. The lack of available convenient transportation is often cited as a major barrier in community follow-up care.^{[16,18,36,37,39]} The data was not analyzed to determine which of the "sometimes" study participants utilized the one outpatient health care facility not easily accessible by public transportation.

Limitations

Several issues need to be noted related to limitations of the study.

Future Research

The first key goal of this study was to make a contribution, however modest, to the growing body of research that expands health information professionals' understanding of barriers adult asthmatics encounter accessing services in community settings. The research presented here provides support that barriers related to organizational, clinician or patient specific impact the quantity and quality of follow-up care. The empirical explorations make a new contribution by highlighting important barrier relationships between HRQL and compliance. Further research is needed to explore and confirm both of these findings.

The second long-run objective of any applied research among chronically ill adults is to assist clinicians in developing effective strategies to improve the lives of patients and their families. The present study of the effect of barriers on HRQL and compliance in adult asthmatics raises the possibility that strategies designed to decrease the perceived barriers of "lack of transportation," "someone missing work," and "inconvenient office hours" may improve follow-up care in this population. Such strategies would operate primarily (or even exclusively) through improving access and thus fostering asthma care in the community where it can be effectively managed. A program that limits barriers might improve compliance with the treatment regime, thus decreasing costs, absenteeism, and lack of continuity. Furthermore, HRQL may improve as a direct result of successfully treating asthma as a chronic disease and not sporadically when exacerbations occur.

Naturally, extensive clinical work guided by empirically informed theory, would be required to develop and test such programs. The present research is a small, but hopefully useful, step forward in the important efforts to identify barriers that are central to HRQL and compliance among adult asthmatics followed in community health care facilities.

Center for Disease Control [homepage on the Internet] Washington DC. (Cited 2008 Jan. 11). Summary health statistics for U.S. adults: National health interview survey 2006. Available from http://www.cdc.gov/nchs/data/series/sr_10/sr10_235.pdf. Mannino, D. M., Homa, D. M., Akinbami, L. J., Moorman, J. E., Gwynn, C., et al. (2002, cited 2003 Oct. 30). Atlanta: Surveillance for asthma: United States, 1980-1999. Available from http://www.cdc.gov.mmwr/PDF/SS555101.pdf. Action against asthma: A strategic plan for the development of health and human services. (n.d., cited 2003 Oct. 30). Available from http://www.aspe.hhs.gov. Chang, C. L., Marmot, M. G., Failey, T. M., & Poulter, N. R. (2002). The influence of economic development on the association between education and the risk of acute myocardial infarction and stroke. Journal of Clinical Epidemiology, 55, 741-747. Eisner, M. D., Katz, P. P., Yelin, E. H., Shiboski, S. C., & Blanc, P. D. (2001). Risk factors for hospitalization among adults with asthma: The influence of sociodemographic factors and asthma severity. Respiratory Research, 2, 53-60. Lacey, E. A., & Walters, S. J. (2003). Continuing inequality: Gender and social class influences on self perceived health after a heart attack. Journal of Epidemiology and Community Health, 57, 622-627. Perry, H. M., & Roccella, E. J. (1998). Conference report on stroke mortality in the southeastern United States. Hypertension, 31, 1206-1215. Haas, J. S., Cleary, P. D., Guadagnoli, E., Fanta, C., & Epstein, A. M. (1994). The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma. Journal of General Internal Medicine, 9, 121-126. Newacheek, P. W., McManus, M., Fox, H. B., Hung, Y., & Halfon, N. (2000). Access to health care for children with special health care needs. Pediatrics, 165, 760-766. Pappas, G., Queen, S., Hadden, W., & Fisher, G. (1993). The increasing disparity in mortality between socioeconomic groups in the United States, 1960-1986. New England Journal of Medicine, 329, 103-109. Riporella-Muller, R., Selby-Harrington, M. L., Richardson, L. A., Donat, P., Luchok, K. J., & Quade, D. (1996). Barriers to the use of preventive health care services for children. Public Health Reports, 111, 71-77. Bender, B. G. (2002). Overcoming barriers to nonadherence in asthma treatment. Journal of Allergy and Clinical Immunology, 109, S554-S559. Crain, E. F., Kercsmar, C., Weiss, K. B., Mitchell, H., & Lynn, H. (1998). Reported difficulties in access to quality care for children with asthma in the inner city. Archives of Pediatrics and Adolescent Medicine, 152, 333-339. Davidson, A. E., Klein, D. E., Settipane, G. A., & Alario, A. J. (1994). Access to care among children visiting the emergency room with acute exacerbations of asthma. Annals of Allergy, 72, 469-473. Kerr, E. A., & Siu, A. L. (1993). Follow-up after hospital discharge: Does insurance make a difference? Journal of Health Care for the Poor and Underserved, 4, 133-142. Munro, J. F., Haire-Joshu, D., Fisher, E. B., & Wedner, H. J. (1996). Articulation of asthma and its care among low-income emergency care recipients. Journal of Asthma, 33, 313-325. Mansour, M. E., Lanphear, B. P., & DeWitt, T. G. (2000). Barriers to asthma care in urban children: Parent perspectives. Pediatrics, 106, 512-519. Rask, K. J., Williams, M. V., Parker, R. M., & McNagny, S. (1994). Obstacles predicting lack of a regular provider and delays in seeking care for patients at an urban public hospital. JAMA, 271, 1931-1933. Kiefe, C. I., & Harrison, P. L. (1993). Post-hospitalization follow-up appointment keeping among the medically indigent. Journal of Community Health, 18, 271-282. Weisman, J. S., Stern, R., Fiedling, S. L., & Epstein, A. M. (1991). Delayed access to health care: Risk factors, reasons, and consequences. Annals of Internal Medicine, 114, 325-331. Jacobs, J. E., van de Lisdonk, E. H., Smeele, I., van Weel, C., & Grol, R. P. T. M. (2001). Management of patients with asthma and COPD: Monitoring quality of life and the relationship to subsequent GP interventions. Family Practice, 18, 574-580. Pinnock, H., Bawden, R., Proctor, S., Wolfe, S., Scullion, J., Price, D., et al. (2003). Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: Pragmatic, randomized controlled trial. BMJ, 326, 1-5. Thoonen, B. P. A., Schermer, T. R. J., van den Boom, G., Molema, J., Folgering, H., et al. (2003). Self-management of asthma in general practice, asthma control and quality of life: A randomized controlled trial. Thorax, 58, 30-36. Erickson, S. R., Christian, R. D., Jr, Kirking, D. M., & Halman, L. J. (2001). Relationship between patient and disease characteristics, and health-related quality of life in adults with asthma. Respiratory Medicine, 96, 450-460. Blixen, C. E., Havstad, S., Tilley, B. C., & Zoratti, E. (1999). A comparison of asthma-related healthcare use between African-Americans and Caucasians belonging to a health maintenance organization (HMO). Journal of Asthma, 36, 195-204. Kanter, L. J., Siegel, C. J., Synder, C. F., Pelletier, E. M., Buchner, D. A., & Gass, T. F. (2002). Impact of respiratory symptoms on health-related quality of life and medical resource utilization of patients treated by allergy specialists and primary care providers. Annals of Allergy, Asthma & Immunology, 89, 139-147. Juniper, E. F., Guyatt, G. H., Cox, F. M., Ferrie, P. J., & King, D. R. (1999). Development and validation of the mini asthma quality of life questionnaire. European Respiratory Journal, 14, 32-38. Leidy, N. K., & Coughlin, C. (1998). Psychometric performance of the asthma quality of life questionnaire in a US sample. Quality of Life Research, 7, 127-134. Higgs, Z. E., Bayne, T., & Murphy, D. (2001). Health care access: Consumer perspective. Public Health Nursing, 18, 3-12. Asch, D. A., Jedrziewski, M. K., & Christaleis, N. A. (1997). Response rates to mail surveys published in medical journals. Journal of Clinical Epidemiology, 30, 1129-1136. Allegheny County Health Department Statistics. (n.d.). Retrieved May 28, 2006 from:www.achd.net/BRFSS/pubs/pdf/asthma.pdf. Center for Disease Control. (2006). [homepage on the Internet] Washington DC: 2006 {cited 2006 July 19}.Summary health statistics for U.S. adults: National health interview survey, 2004. Available from: http://www.cdc.gov/nchs/data/series/sr_10/sr10_228.pdf. Baren, J. M., Shofer, F. S., Iven, B., Reinhard, S., DeGus, J., Stahmer, S. A., et al. (2001). A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations. Annals of Emergency Medicine, 38, 115-122. Goerman, D. P., Aroni, R. A., Sayer, S. M., Stewart, K., Thien, F. C., Abramson, M. J., et al. (2004). Back for more: A qualitative study of emergency department reattendance for asthma. Medical Journal of Australia, 180, 113-117. Murray, M. D., Stang, P., & Tierney, W. M. (1997). Health care use by inner-city patients with asthma. Journal of Clinical Epidemiology, 50, 167-174. Jerant, A. F., von Friederichs-Fitzwater, M. M., & Moore, M. (2004). Patients' perceived barriers to active self-management of chronic conditions. Patient Education and Counseling, 57, 300-307. Smith, S. R., Highstein, G. R., Jaffe, D. M., Fisher, E. B., & Strunk, R. C. (2002). Parental impressions of the benefits (pros) and barriers (cons) of follow-up care after an acute emergency department visit for children with asthma. Pediatrics, 110, 323-330. Valerio, M., Cabana, M. D., White, D. F., Heidmann, D. M., Brown, R. W., & Bratton, S. L. (2006). Understanding of asthma management: Medicaid parents' perspectives. Chest, 129, 594-601. Field, K. S., & Briggs, D. J. (2001). Socio-economic and locational determinants of accessibility and utilization of primary health-care. Health & Social Care in the Community, 9, 294-308. Cisternas, M. G., Blanc, P. D., Yen, I. H., Katz, P. P., Earnest, G., Eisner, M. D., et al. (2003). A comprehensive study of the direct and indirect costs of adult asthma. Journal of Allergy and Clinical Immunology, 111, 1212-1218. Niefeld, M., & Kasper, J. D. (2005). Access to ambulatory medical and long-term care services among elderly Medicare and medicaid beneficiaries: Organizational, financial, and geographic barriers. Medical Care Research and Review, 62, 300-319. Ahmed, S. M., Lemkqu, J. P., Nealeigh, N., & Mann, B. (2001). Barriers to healthcare access in a non-elderly urban poor American population. Health & Social Care in the Community, 9, 445-453. Diette, G. B., Krishnan, J. A., Dominici, F., Haponik, E., Skinner, E. A., Steinwachs, D., et al. (2002). Asthma in older patients. Archives of Internal Medicine, 162, 1123-1132. Eisner, M. D., Ackerson, L. M., Chi, F., Kalkbrenner, A., Buchner, D., Mendoze, G., et al. (2002). Health-related quality of life and future health care utilization for asthma. Annals of Allergy, Asthma & Immunology, 89, 46-55. Barr, R. G., Somers, S. C., Spetzer, F. E., & Camargo, C. A. (2002). Patient factors and medication guideline adherence among older women with asthma. Archives of Internal Medicine, 162, 1761-1768. Zoratti, E. M., Havstad, S., Rodriguez, J., Robens-Paradise, Y., Lafata, J. E., & McCarthy, B. (1998). Health service use by African-Americans and Caucasians with asthma in a managed care setting. American Journal of Respiratory and Critical Care Medicine, 158, 371-377. Boudreaux, E. D., Emond, S. D., Clark, S., & Camargo, C. A. (2003). Acute asthma among adults presenting to the emergency department: The role of race/ethnicity and socioeconomic status. Chest, 124, 803-812. Apter, A. J., Reisine, S. T., Affleck, G., Barrows, E., & ZuWallack, R. L. (1999). The influence of demographic and socioeconomic factors on health-related quality of life in asthma. Journal of Allergy and Clinical Immunology, 103, 72-78. Blanc, P. D., Yen, I. H., Chen, H., Katz, P. P., et al. (2006). Area-level socio-economic status and health status among adults with asthma and rhinitis. European Respiratory Journal, 27, 85-94. Laforest, L., Pacheco, Y., Bartsch, P., Vinchen, W., et al. (2005). Correlates of quality of life in patients with asthma. Annals of Allergy, Asthma & Immunology, 94, 473-479. Wilson, D. H., Chittleborough, C. R., Kirke, K., Grant, J. F., et al. (2004). The health related quality of life of male and female heavy smokers. Sozial- und Praventivmedizin, 49, 406-412. Marcus, B., & Schutz, A. (2005). Who are the people reluctant to participate in research? Personality correlates of four different types of nonresponse as inferred from self- and observe ratings. Journal of Personality, 73, 959-984.

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Rosemary L. Hoffmann, Email: rho100@pitt.edu

Rosemary L. Hoffmann,¹ Wesley M. Rohrer III,² Jeannette E. South-Paul,³ Ray Burdett⁴ and Valerie J. M. Watzlaf<sup>5

1</sup> University of Pittsburgh School of Nursing, 3500 Victoria Boulevard, 336 Victoria Building, Pittsburgh, PA 15261, USA
² Health Management Education in the Department of Health, Policy & Management, A646 Crabtree Hall, Pittsburgh, PA 15213, USA
³ Department of Family Medicine, University of Pittsburgh School of Medicine, 3518 Fifth Avenue, Pittsburgh, PA 15261, USA
⁴ Undergraduate Programs, University of Pittsburgh School of Health & Rehabilitation Science, 6022 Forbes Tower, Pittsburgh, PA 15213, USA
⁵ Department of Health Information Management, University of Pittsburgh School of Health & Rehabilitation Science, 6030 Forbes Tower, Pittsburgh, PA 15213, USA