Because adherence to therapy is an integral part of the effective management of asthma, all international public health efforts to improve asthma outcomes should include educational strategies for both patients and health care providers that target the promotion of adherence. Regular adherence to ICS therapy is dependent on the patient's acceptance that asthma is a chronic disease requiring preventive treatment. Patients must also feel that the prescribed therapy is effective in achieving the desired treatment goals and is safe for long-term use. Several studies have confirmed that the beliefs that patients hold about their asthma and the therapy prescribed for it are closely associated with the likelihood of adherence. When patients do not perceive that their asthma is chronic or that it requires preventive treatment, adherence with therapy is generally episodic.

Effective communication between patients and providers has been identified as having an important influence on patients' adherence. Most health professionals lack the training to change the behaviour of nonadherent patients. Educational efforts sponsored by both public and private sources are needed to improve the communication skills of health professionals so as to promote adherence to the treatments recommended for asthma.

Limited evidence from studies of adherence to asthma therapy among immigrant populations in developed countries suggests that use of alternative medicine and lay beliefs may significantly reduce adherence to therapy. Watson and Lewis (68) reported that inhaled corticosteroids were available in only 15 of 24 countries surveyed in Africa and Asia, and when available the median (range) cost of a 50 µg beclomethasone inhaler was 20% (6.8 - 100%) of the average local monthly income. Additional research is needed on the rates of adherence and barriers to adherence in developing countries.

Guidelines on the management of patients with asthma may be modified in the future following the development of accurate and affordable systems for monitoring anti-inflammatory medication. By objectively evaluating the adherence of symptomatic patients, those who are nonadherent may be identified, appropriately treated and counselled in an accurate, efficient and cost-effective manner (69).