Non-Compliance with Inhaled Corticosteroid (ICS) Among Asthma Patients in Yazd City, Iran
Last reviewed: March 2026
Key Findings
- Among 112 adult asthma patients in Yazd, 55.4% did not use their prescribed inhaled corticosteroids (ICS), representing a significant non-compliance rate.
- Patients’ knowledge about ICS, attitudes and health beliefs toward ICS therapy, and behavioural intention to adhere were assessed as key compliance determinants.
- Lack of information about prescribed drugs and health conditions was identified as the primary driver of medication non-adherence.
- The study was the first of its kind conducted in Yazd City and provided a baseline for asthma management interventions in the region.
Background
Asthma affects approximately 300 million people worldwide and remains one of the most common chronic respiratory diseases globally. Inhaled corticosteroids (ICS) are the cornerstone of long-term asthma management, functioning as anti-inflammatory agents that reduce airway hyperresponsiveness, decrease exacerbation frequency, and improve overall lung function. International guidelines, including those from the Global Initiative for Asthma (GINA), consistently recommend ICS as first-line maintenance therapy for persistent asthma across all severity levels.
Despite the well-established efficacy of ICS, non-compliance with prescribed therapy remains a pervasive challenge in asthma management worldwide. Studies across diverse healthcare settings have documented ICS non-adherence rates ranging from 22% to over 80%, depending on the population studied and the method used to assess adherence. The consequences of ICS non-compliance are substantial: increased frequency of acute exacerbations, higher rates of emergency department visits and hospitalisations, greater reliance on rescue bronchodilators, accelerated decline in lung function, and increased healthcare costs.
In Iran and other Middle Eastern countries, the burden of asthma is considerable, yet research on ICS compliance in these populations has been limited. Yazd, a city in central Iran, had not been the subject of any prior study examining asthma treatment adherence patterns, creating a significant evidence gap for local healthcare planning.
Study Design and Methods
This cross-sectional study was conducted between August 2008 and January 2009 across three private allergy and asthma clinics in Yazd City. A total of 112 adult asthmatic patients who had been prescribed ICS participated in structured face-to-face interviews using a standardised questionnaire. The questionnaire assessed multiple domains including socio-demographic characteristics, knowledge about ICS therapy, attitudes toward long-term ICS use, health beliefs regarding the necessity and potential harms of ICS, and behavioural intention to adhere to the prescribed regimen.
The majority of participants had diploma-level education or higher (100 out of 112), indicating a relatively educated sample. This was relevant because educational attainment has been identified as both a potential facilitator and barrier to medication adherence — higher education may enhance understanding of treatment rationale but may also increase scepticism about long-term medication use.
Compliance Rates and Patterns
The central finding was that 55.4% of patients did not use their prescribed ICS. This rate of non-compliance is consistent with rates observed in similar Middle Eastern populations and aligns with the broader international literature documenting that approximately half of chronic disease patients do not take medications as prescribed. Investigation into the reasons for non-compliance revealed that the lack of information about prescribed drugs and their role in disease management was the most frequently cited barrier.
The assessment of patient knowledge revealed that while most patients understood the basic concept of asthma as a chronic condition, significant gaps existed in their understanding of the specific role of ICS in long-term disease control. Many patients conflated ICS with rescue bronchodilators (such as salbutamol), failing to recognise that ICS provides prophylactic anti-inflammatory benefit rather than immediate symptom relief. This confusion contributed to a pattern of using ICS only during symptomatic episodes rather than as prescribed daily maintenance therapy.
Knowledge, Attitudes, and Health Beliefs
The study assessed mean scores across several psychosocial domains related to ICS adherence. Knowledge of asthma and ICS, attitudes toward treatment, and health beliefs about the necessity of medication versus concerns about potential side effects were all measured using validated scales. The results indicated that knowledge scores were generally moderate, with room for significant improvement, particularly regarding the anti-inflammatory mechanism of ICS and the importance of daily use even during asymptomatic periods.
Health beliefs played a particularly important role in shaping adherence behaviour. Patients who perceived their asthma as a serious condition requiring ongoing management were more likely to adhere to ICS therapy, while those who viewed asthma as an episodic condition requiring treatment only during flare-ups were more likely to be non-compliant. Concerns about potential side effects of long-term ICS use — including fears about steroid dependency, weight gain, and osteoporosis — were also identified as barriers to adherence, even though the systemic side effect profile of inhaled corticosteroids at standard doses is generally favourable.
Implications for Clinical Practice
The findings underscore the critical importance of patient education in asthma management. Healthcare providers must invest time in explaining not only how to use ICS devices correctly but also why daily maintenance therapy is necessary and how it differs from rescue medication. Educational interventions should specifically address common misconceptions about ICS, including unfounded fears about steroid side effects at therapeutic inhaled doses.
The study also highlights the potential value of pharmacist-led counselling programmes, patient support groups, and written action plans in improving ICS adherence. In settings where face-to-face counselling time is limited, multimedia educational materials — including videos demonstrating correct inhaler technique and explaining the pathophysiology of airway inflammation — may supplement clinical consultations.
Global Relevance
While conducted in an Iranian setting, this study’s findings resonate with the global challenge of medication non-adherence in chronic disease management. The 55% non-compliance rate is remarkably consistent with WHO estimates that adherence to long-term therapies for chronic conditions in developed countries averages approximately 50%, with rates expected to be even lower in developing countries. The study has been cited in subsequent research from Kuwait, Egypt, and other Middle Eastern countries examining ICS adherence patterns, confirming its contribution to the regional evidence base.
Limitations
The study’s cross-sectional design limits causal inference about the relationship between knowledge, attitudes, and adherence behaviour. The sample was drawn from private allergy clinics, which may not represent the broader population of asthma patients in Yazd, particularly those receiving care in public healthcare facilities. Self-reported adherence may be subject to social desirability bias, potentially leading to underestimation of the true non-compliance rate. The study did not assess clinical outcomes such as exacerbation rates or lung function parameters, which would have strengthened the demonstration of the clinical impact of non-adherence.
Rahim A, Sulong S, Maimaiti N, Ghazi HF. Non-Compliance with Inhaled Corticosteroid (ICS) Among Asthma Patients in Yazd City, Iran. Malaysian Journal of Public Health Medicine. 2013;13(2):77–87.
License: Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)