Children. There can be great diversity among families in how medication is managed. The responsibility for administration of medication generally shifts as a child grows, from total parental management for a young child, to shared medication management for a school-aged child, to complete self-management for an adolescent. Day-care providers, grandparents and siblings may assume the responsibility for the regular delivery of asthma medication in some households. In chaotic, troubled families there may be confusion as to who has the primary responsibility for the medication monitoring. The age at which a child is capable of assuming responsibility for remembering to take daily medication is highly variable, and is more a reflection of the child's maturity and personality than his or her chronological age. In some families children may be expected to manage their own medication early, less because the child has demonstrated sufficient responsibility, than because the parent believes the child is old enough to do it. For older children and adolescents, asthma management has the potential for turning into a battle in the war of independence. Research on juvenile diabetes, haemophilia and rheumatoid arthritis has emphasized the particular vulnerability of adolescents to problems with adherence to medication (37,38). Family conflict and a denial of disease severity in an adolescent with severe asthma should therefore suggest a patient at a high risk for nonadherence to therapy.

Elderly patients. Some barriers to adherence to therapy are more common in older patients and warrant particular attention in clinical management. For example, although patients of any age may forget to take their medication, for some older patients memory difficulties may be exacerbated by other medications or early dementia. In addition, older patients are often receiving treatment for several other chronic health conditions simultaneously. The resulting polypharmacy is a well-recognized problem for many elderly patients, presenting both pharmacological and adherence risks (39). The treatment of multiple ailments can result in complicated and burdensome medication regimens that require medications to be taken many times per day. Clinicians treating older patients for asthma should carefully review all prescribed medications, be attentive to potential memory difficulties, and assist the patient in integrating ICS therapy into his or her existing regimens.

Cultural differences. Culture and lay beliefs about illness and treatment can also influence the acceptance of asthma therapies by patients and their families. Diverse cultural beliefs can affect health care through competing therapies, fear of the health care system or distrust of prescribed therapies.

Income. While income per se does not predict adherence, the co-variates of poverty and inner-city living may make adherence to asthma self-management more difficult. Barriers to adherence related to low income can include inconsistent primary health care, inability to pay for asthma medications, lack of transport, family dysfunction and substance abuse (40 - 43).

In some countries, patients may not be able to afford preventive asthma therapies. Research suggests that these cost barriers may lead some patients to treat their disease only during periods of exacerbation, or to reduce their dosage to "stretch" their medication.