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ORIGINAL RESEARCH
Asthma impacts on workplace productivity in
employed patients who are symptomatic despite
background therapy: a multinational survey
This article was published in the following Dove Press journal:
Journal of Asthma and Allergy
Kevin Gru ffydd-Jon es
1
Mike Thomas
2
Miguel Roman-Rodríguez
3
Antonio Infantino
4
JMarkFitzGerald
5
Ian Pavord
6
Jennifer M Haddon
7
Ulrich Elsasser
8
Christian Vogelberg
9
1
Box Surgery, Box, Wiltshire, UK;
2
Primary Care and Population Sciences,
University of Southampton,
Southampton, UK;
3
SonPisàPrimary
Health Care Centre, Balearic Health
Centre, Palma de Mallorca, Spain;
4
Società Italiana Interdisciplinare per le
Cure Primarie (SIICP), Bari, Italy;
5
Institute for Heart and Lung Health,
University of British Columbia,
Vancouver, British Columbia, Canada;
6
Respiratory Medicine Unit and Oxford
Respiratory NIHR Biomedical Research
Centre, Nuffield Department of
Medicine, University of Oxford, Oxford,
UK;
7
TA Dig Excellence + Healthcare
Inno Med, Boehringer Ingelheim
International GmbH, Ingelheim am Rhein,
Germany;
8
Biostatistics and Data
Sciences, Boehringer Ingelheim Pharma
GmbH & Co. KG, Biberach an der Riss,
Germany;
9
Department of Pediatric
Pneumology and Allergology, University
Hospital Carl Gustav Carus, Technical
University of Dresden, Dresden,
Germany
Background: Asthma affects millions of people worldwide, with many patients experien-
cing symptoms that affect their daily lives despite receiving long-term controller medication.
Purpose: Work is a large part of most people’s lives, hence this study investigated the
impact of uncontrolled asthma on work productivity in adults receiving asthma maintenance
therapy.
Patients and methods: An online survey was completed by employed adults in Brazil,
Canada, Germany, Japan, Spain and the UK. Participants were confirmed as symptomatic
using questions from the Royal College of Physicians’3 Questions for Asthma tool. The
survey contained the Work Productivity and Activity Impairment –Specific Health Problem
questionnaire and an open-ended question on the effect of asthma at work.
Results: Of the 2,055 patients on long-term maintenance therapy screened, 1,598 were
symptomatic and completed the survey. The average percentage of work hours missed in a
single week due to asthma symptoms was 9.3%, ranging from 3.5% (UK) to 17.4% (Brazil).
Nearly three-quarters of patients reported an impact on their productivity at work caused by
asthma. Overall work productivity loss (both time off and productivity whilst at work) due to
asthma was 36%, ranging from 21% (UK) to 59% (Brazil). When asked how asthma made
participants feel at work, many respondents highlighted how their respiratory symptoms
affect them. Tiredness, weakness and mental strain were also identified as particular chal-
lenges, with respondents describing concerns about the perception of colleagues and feelings
of inferiority.
Conclusions: This study emphasizes the extent to which work time is adversely affected by
asthma in patients despite the use of long-term maintenance medication, and provides unique
personal insights. Strategies to improve patients’lives may include asthma education,
optimizing asthma management plans and running workplace well-being programs.
Clinicians, employers and occupational health teams should be more aware of the impact
of asthma symptoms on employees, and work together to help overcome these challenges.
Keywords: work productivity, asthma, burden, costs
Plain language summary
Asthma can make daily life difficult for millions of people worldwide. We surveyed people
who have asthma to find out how it affects their work lives. These people had asthma
symptoms despite taking long-term treatment. Over 1,500 people in Brazil, Canada,
Germany, Japan, Spain and the UK completed an online survey. This survey showed that
workers missed nearly one-tenth of their weekly work due to their asthma. Three out of four
workers felt they could not work to their full potential because of their illness. Asthma
Correspondence: Kevin Gruffydd-Jones
Box Surgery, London Road, Box,
Wiltshire SN13 8NA, UK
Tel +44 122 574 4195
Fax +44 122 574 2646
Email k.gruffydd-jones@nhs.net
Journal of Asthma and Allergy Dovepress
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reduced work productivity by more than a third. Personal insights
showed the impact of asthma on their emotional well-being at
work, including tiredness, weakness and mental strain. Study
participants also described feelings of desperation, stress, embar-
rassment, helplessness and guilt. It shows how much poorly
treated asthma symptoms can impact society. We encourage
both healthcare workers and workplaces to act together to
improve the lives of people with asthma.
Introduction
Globally, asthma is the most prevalent chronic respiratory
disease, with recent estimates showing it directly affects
over 358 million individuals.
1
In spite of the development of
effective treatments and new management paradigms, asthma
continues to have a huge impact on patients’lives, with over
45% of patients with asthma estimated as having poorly con-
trolled disease.
2,3
International trends have shown that during
the period 2006–2012 there was no significant reduction in
global asthma mortality rates, which remained at 0.19 deaths
per 100,000 people.
4
Further to this, asthma causes a burden in
terms of impaired quality of life and physical, psychological
and social disability, with estimates that asthma accounts for
1% of disability-adjusted life-years lost worldwide.
5,6
Poorly controlled asthma is associated with reduced work
productivity versus well-controlled asthma.
7–9
In a European
study, 24–59% of surveyed patients with asthma reported at
least 1 day of absence from work or education in the previous
year.
7
In a US study, workers with poorly controlled asthma
(39.7% of respondents) had greater work and activity impair-
ment versus those with well-controlled asthma.
8
These find-
ings were also echoed in a recent prospective study in Canada
assessing work-related asthma, which looked at two aspects
involved in productivity loss:presenteeism (which represents
the impact on productivity whilst working) and absenteeism
(which only represents time taken off work). In the study,
people with uncontrolled asthma had greater productivity
loss compared with those with controlled asthma, and the
productivity loss due to presenteeism was greater than loss
due to absenteeism.
10
Another study in Canada showed that
optimizing asthma control improved presenteeism to a
greater extent than absenteeism, and therefore presenteeism
represents an important preventable burden.
11
In an
Australian study, improving asthma control was again
found to be an important target for optimizing workplace
productivity, with presenteeism and impairment in daily
activity more frequently reported in severe versus non-severe
asthma.
12
This highlights the importance of evaluating
presenteeism when considering productivity loss and the
overall economic burden of asthma.
There is a substantial economic burden of time lost at
work due to asthma. This impact on work productivity is not
only on the individual (in terms of sick pay/hours lost and
their well-being), but also affects colleagues, employers and
society as a whole.
13–15
A study in Spain reported that
indirect costs were significantly higher in the 57.6% of
patients with poorly controlled asthma compared with
patients whose disease was controlled.
9
The cost of care-
takers of dependents with asthma taking time off work con-
tributes a large proportion of the indirect costs associated
with asthma.
15
Poor asthma control in children also impacts
the quality of life and productivity of caregivers.
16
Reports
from around the world have shown that the detrimental
effects of inadequately controlled asthma start in childhood
and impact both school productivity and attendance.
17–19
A key part of this current study is that it recruited patients
already treated with controller medication, and investigated
the persisting impact of asthma on a patient’s ability to work.
The study also measured a patient’s ability to work to their
full potential, which can often be overlooked in the assess-
ment of asthma, when attention can be on other daily activ-
ities. The findings of this current study should enhance our
understanding of the burden of asthma across continents.
This is the first transcontinental survey that we are
aware of that aimed to assess quantitative measures of
work productivity and collected personal insights from
adults with symptomatic asthma who receive long-term
controller medication.
Methods
Study design
The survey was designed to collect both quantitative and
qualitative data on the effect of asthma at work in individuals
with asthma that were poorly controlled despite receiving
long-term asthma maintenance therapy. The survey was car-
ried out between April–September 2015 by Research Now
®
(London, UK). Participants were recruited from six coun-
tries: Brazil, Canada, Germany, Japan, Spain and the UK. A
random sample of approximately 60,000 individuals from
the online consumer panel of Research Now
®
who had pre-
viously been profiledasadultasthmasufferersinemploy-
ment were invited via email to participate in this survey on
the topic of “healthcare”(Figure 1). One exception to this
was Japan, where the consumer panel had not previously
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been screened for asthma or employment. For Japan,
approximately 520,000 people were initially invited, with
approximately 50,000 responding and being screened for
eligibility. The questionnaire was translated for each country.
The 6,140 eligible individuals from the six countries
who responded to the invitation, who were confirmed as
being over 18 years old and as having asthma diagnosed
by a healthcare professional, were then further screened
for eligibility, which included being in employment and
being symptomatic despite receiving a long-term asthma
controller medication (Figure 1; screener questions are
detailed in the supplementary materials section). The sur-
vey respondents provided their consent to participate in the
survey online before answering any of the screening ques-
tions, and all data were anonymized. All eligible patients
were then asked to complete the online survey containing
the Work Productivity and Activity Impairment –Specific
Health Problem (WPAI-SHP) questionnaire to describe
how asthma had impacted their lives in the previous
week, and to answer an additional open-ended question:
“How does your asthma at work make you feel?”(see
supplementary materials).
The survey was conducted to conform with Market
Research Society regulations, and the codes of conduct of
the Market Research Society, British Healthcare Business
Intelligence Association and European Pharmaceutical
Market Research Association. Therefore, ethics approval
was not sought. Respondents provided consent to partici-
pate in the survey by selecting a yes/no option before
entering the screening questionnaire.
Consumer panel
previously screened for
asthma; invited from
Brazil, Canada,
Germany, Spain and
the UK
N˜60,000
Consumer panel not
previously screened
for asthma; invited
from Japan
N˜520,000
Did not respond to survey, or did
not fulfill initial criteria (diagnosed
asthma and ≥18 years old), or did
not agree to the survey disclaimer
n˜570,000
Consumer panel participants:≥18 years old with
asthma diagnosed by a healthcare professional
n=6,140
Long-term asthma control inhaler /
preventer medication not selected
n=1,945
Not currently employed
n=2,140
In full- or part-time employment
n=4,000
Receiving long-term asthma control inhaler /
preventer medication
n=2,055
Symptomatic asthma despite controller medication;
completed the WPAI-SHP online questionnaire
n=1,598
‘No’ selected for all three RCP3Q
questions
n=457
IdentificationScreeningWPAI-SHP
Figure 1 Participant selection. The initial part of the survey included screening questions to ensure eligible participation. This included patients who were: over 18 years old;
had asthma diagnosed by a healthcare professional; were in employment; were on long-term asthma control; and who had asthma that affected their sleep/daytime or usual
activity in the previous month (see supplementary materials).
Abbreviations: RCP3Q, Royal College of Physicians’3 Questions for Asthma; WPAI-SHP, Work Productivity and Activity Impairment –Specific Health Problem.
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As is common practice to reduce non-response bias,
the survey was short (taking approximately 5 mins), each
participant was offered a nominal incentive (ie, a small
honorarium) for completing the survey, and reminders
were sent to all participants. Each country had a quota
for the overall number of respondents, which was nation-
ally representative of the population size.
Participants
The survey participants were adults (aged ≥18 years) with
asthma diagnosed by a healthcare professional. They were in
either full- or part-time employment, and were currently
receiving treatment with long-term asthma maintenance with
or without reliever therapy. During screening, survey partici-
pants were confirmed as symptomatic using questions from
the Royal College of Physicians’3 Questions for Asthma
morbidity scoring tool, which provided an indication of poor
asthma control (see supplementary materials).
20,21
If a partici-
pant answered “yes”to any of the three questions (ie, a score
of ≥1), they were identified as having poor asthma control and
were then directed immediately to the WPAI-SHP section of
the questionnaire.
Work Productivity and Activity
Impairment –Specific Health Problem
Questionnaire
The WPAI-SHP questionnaire is a validated tool that quan-
tifies the extent of work loss and impairment due to poor
health, as well as the symptom or problem specified.
22
The
questionnaire is a patient-reported quantitative assessment
of the amount of impairment during the previous 7 days
(see supplementary materials). Version 2.0 of this question-
naire was used, which repeats instructions directly above
the scales for questions 5 and 6 to improve the accuracy of
response.
23
To br iefly summarize, this questionnaire exam-
ines absenteeism (work time missed due to asthma), pre-
senteeism (how asthma impairs productivity during
working), total work productivity loss (a combination of
absenteeism and presenteeism) and activity impairment in
daily activities other than work.
24
Statistical analysis
Descriptive statistics were used to summarize the quantita-
tive data collected in this survey. The questions of the
WPAI-SHP cover the following: Q1, employment status;
Q2, number of hours missed due to asthma; Q3, number of
hours missed due to other reasons; Q4, total number of
hours worked; Q5, the degree to which asthma impairs
productivity whilst working; and Q6, the degree to which
asthma impairs regular daily activities.
23
Absenteeism is
expressed as the percentage of the working time of the
week missed due to asthma (Q2/[Q2+Q4]x100). Both the
impact on work productivity and regular daily activities
were reported by the patient on a scale of 0–10; this was
then categorized as follows: 0, no effect; 1–3, small effect;
4–7, medium effect; and 8–10, large effect. A prominent
impairment in this study was considered as a score of >4.
Total work productivity loss is calculated using the follow-
ing equation from the standard WPAI-SHP questionnaire:
Q2/(Q2+Q4)+([1-(Q2/[Q2+Q4])]x[Q5/10]). This calcula-
tion takes into consideration the amount of time lost (absen-
teeism) and the degree of impairment affected whilst also
working to produce an overall percentage that summarizes
the work impairment due to asthma.
In addition, the two endpoints ‘Overall impairments
due to asthma’and ‘Total work productivity loss’were
analyzed by analysis of variance (ANOVA), with country
and chronic obstructive pulmonary disease (COPD), and
country and age, as factors. Two ANOVA models were
applied, including and excluding the interaction.
Qualitative data
All participants who completed the survey were also asked
an open-ended question: Q7 “How does your asthma at
work make you feel?”To allow common themes to be
identified from this qualitative section, all the verbatim
answers were converted into descriptors as part of a code
frame created specifically for this project; these descriptors
were then arranged into categories. For example, partici-
pants used various ways to describe their respiratory
impairment by using words such as “suffocated”,“dys-
pnea/shortage of breath”or “chest pain”; these words then
became descriptors that were then included in the category
“Respiratory symptoms”. A further example is the use of
words such as “isolated”,“self-conscious”and “stressed”,
which were provided by participants to describe their
feelings when their asthma affected them in the workplace;
these became descriptors that were then included in the
category “Mentally strained”. Each individual’s response
to the open question could identify difficulties that
belonged in more than one category (ie, a survey partici-
pant could describe themselves both as having respiratory
symptoms and being mentally strained). A list of the
common descriptors based on responses from ≥3 study
participants is found in Table S1.
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Results
Patient characteristics
Of the 2,055 survey respondents screened that were in
employment and receiving a long-term asthma control inhaler
and/or preventer medication, 457 were asymptomatic; the
remaining 1,598 were classed as symptomatic (Figure 1).
Patient characteristics are summarized in Table 1.Awide
age range was sampled, with nearly half of respondents aged
over 40 years. Three-quarters of patients were in full-time
employment. Of the comorbidities included in the question-
naire, high blood pressure and high cholesterol were common
comorbidities, each affecting approximately 20% of survey
participants.
WPAI-SHP results
In total, 1,598 symptomatic participants completed the
online WPAI-SHP questionnaire. Due to asthma, 9.3% of
the working week was missed, with a range of 3.5% in the
UK to 17.4% in Brazil (Figure 2). Amongst both full- and
part-time workers, this averaged to 3.4 hrs in 1 week.
In terms of presenteeism, 74% of participants reported
a reduction in productivity at work caused by asthma
(score 1–10), with 42% reporting a prominent reduction
(score ≥4/10; Figure 3). Overall work productivity loss (a
figure that combines both absenteeism and presenteeism)
due to asthma was 36%; this ranged from 21% in the UK
to 59% in Brazil (Figure S1). Further to this, asthma
affected 83% of respondents’ability to perform regular
daily activities (score 1–10), with 51% reporting a promi-
nent impairment (score ≥4/10) (Figure 4).
When results were analyzed by COPD and age,
patients with COPD were found to have a higher
mean overall impairment and total work productivity
loss than non-COPD patients. Mean overall impairment
and total work productivity loss both decreased for
patients aged ≥40 years. There was no significant inter-
action between COPD and country or between age and
country. See supplementary materials (Table S2)for
more details.
Work productivity: patient insights
When asked how asthma made participants feel at work, the
most commonly cited challenge was how respiratory symp-
toms directly affected them in the workplace (Figure 5).
Tiredness/weakness, mental strain and physical impairments
were all noteworthy challenges (Figure 5). A further factor was
a negative perception from colleagues due to their asthma
symptoms, which was most notable in Japan and the UK
(Figure S2).
Overall, when asked how asthma makes them feel,
over two-thirds of respondents indicated that asthma had
a negative impact on their work activities.
Selected statements from patients further illustrate this:
[Asthma at work] can make me feel quite self-conscious if
I start coughing or wheezing. I feel guilty if I need to take
a break and take my inhaler.
Sad, depressed and as if I can’t do a lot.
[I] fatigue easily, [and have] difficulty in concentrating.
Perceptions of colleagues were also a common concern:
[E]mbarrassed, as I don’t like using my inhalers in front of
people.
[G]uilty, as colleagues sometimes cover for me.
Feelings of frustration were often coupled with the physi-
cal impairments:
Table 1 Survey participant characteristics
Characteristic Total, n (%)
Asthma diagnosed by a HCP 1,598 (100)
Age, years
18–24 146 (9.1)
25–39 687 (43.0)
40–59 634 (39.7)
≥60 131 (8.2)
Country
Brazil 200 (12.5)
Canada 200 (12.5)
Germany 293 (18.3)
Japan 305 (19.1)
Spain 300 (18.8)
UK 300 (18.8)
Employment status
Full-time 1,213 (75.9)
Part-time 385 (24.1)
Comorbidities
High blood pressure 344 (21.5)
High cholesterol 311 (19.5)
Type 2 diabetes 165 (10.3)
Arthritis 262 (16.4)
COPD 127 (7.9)
Osteoporosis 86 (5.4)
Abbreviations: COPD, chronic obstructive pulmonary disease; HCP, healthcare
professional.
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[F]rustrated at being short of breath and sometimes
embarrassed.
[D]ifficult to communicate with people as breathless.
[L]ess able to walk around quickly/take the stairs.
A number of respondents also felt inferior and disadvantaged:
[M]akes me feel like a big failure.
[M]akes me feel useless.
Regarding their working conditions, one person commented:
I can usually manage my asthma symptoms at work; however,
last week the building was undergoing construction work and
there was a lot of dust around. I’ve had severe asthma symp-
toms and a chest infection for 7 days now due to this. This
made me feel upset, as my working conditions were not
appropriate for me and this was not considered by my
employer.
20 17.4
6.1
10.3
9.0
10.9
9.3
3.5
18
16
14
12
10
8
6
4
2
0
Brazil
Work time missed due to asthma (%)
Canada Germany Japan Spain UK Total
Country
Figure 2 Absenteeism (percentage of hours missed per week due to asthma) by country. Absenteeism captures the percentage of hours missed from work because of
asthma, including hours missed on sick days and time missed from being late or leaving early due to asthma. All respondents (N=1,559); Brazil (n=198); Canada (n=189);
Germany (n=289); Japan (n=301); Spain (n=297); UK (n=285). Error bars represent standard error of the mean.
Brazil 11 17 50 22
827
73438
32
32 29 930
20 28 40 12
41 36 21 3
9333126
34
21
% selecting response
n=197
n=187
n=284
n=295
n=294
n=283
n=1,540
4-7 Medium effect1-3 Small effect0 No effect 8-10 Large effec
t
Canada
Germany
Japan
Spain
UK
Total
Figure 3 Impact of asthma on productivity at work. WPAI-SHP Q5: “During the past seven days, how much did asthma affect your productivity while you were working?”
Answered on a 0–10 score, with 0= asthma had no effect on my work and 10= asthma completely prevented me from working.
Abbreviation: WPAI-SHP, Work Productivity and Activity Impairment –Specific Health Problem.
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Further information on the descriptions used by respon-
dents can be seen in Table S1.
Discussion
Work plays a substantial role in most people’s lives, and
this study has shown that symptomatic asthma has a large
negative impact on a patient’s ability to perform with full
effectiveness at work. In this multinational survey, both
measures of work productivity –absenteeism and presen-
teeism –were affected by asthma symptoms. In the week
leading up to this survey, nearly one-tenth of work time
was missed due to asthma, with almost three-quarters of
asthma patients reporting a reduction in productivity at
work; for 42% of patients, this was a “prominent”reduc-
tion. Comments from the study participants provide mul-
ticultural attitudes about disease burden, symptoms and
Normal/no impairment
Respiratory symptoms
Tired/weak
Mentally strained
Physically impaired
State depends on other factors
Perception of/impact on colleague
Fearful/nervous
Other symptoms
Irritable/annoyed
Inferior/disadvantaged
Number of comments
Challenges Positive comments
0 100 200 300 400 500 600
Figure 5 Survey participant comments and perceived challenges encountered at work due to asthma. Additional open-question 7: “How does your asthma at work make
you feel?”Overall, 1,598 participant responses were recorded from the six countries; each individual could raise more than one challenge.
4-7 Medium effect1-3 Small effect0 No effect 8-10 Large effect
% selecting response
Brazil
Canada
Germany
Japan
Spain
UK
Total
n=200
n=200
n=293
n=305
n=300
n=300
n=1,598
721
20
12
22
13 26
27
17 32 39 12
41
48 26
32 9
9
12
13
6
4534
31 35
48
39 28
Figure 4 Impact of asthma on regular daily activities other than work. WPAI-SHP Q6: “During the past seven days, how much did asthma affect your ability to do your
regular daily activities, other than work at a job?”Answered on a 0–10 score with 0= asthma had no effect on my daily activities and 10= asthma completely prevented me
from doing my daily activities.
Abbreviations: WPAI-SHP, Work Productivity and Activity Impairment –Specific Health Problem.
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employment across a broad age range of patients. They
also offer unique personal insights into the emotional
well-being of employees with uncontrolled asthma and
reveal that challenges faced at work include tiredness,
weakness and mental strain, as well as emotional and
physical impairment. The findings illustrate that there
needs to be further awareness and understanding of the
impact of psychological comorbidities associated with
uncontrolled asthma.
Wide variation in the impact of asthma on absenteeism
and work productivity was observed between the different
countries in this survey, which has also been reported
previously.
7,9,11,25,26
Rising disparities in health expendi-
ture between countries may lead certain populations, or
entire countries, to appear to have a disproportionately
higher asthma morbidity and mortality. This could be a
possible explanation for the between-country differences
observed in this study.
5
Brazil, in particular, had a higher
percentage of missed working hours and loss in productiv-
ity compared with the other countries in this study. This
could be because the survey was conducted between April
to September, which was after the rainy/humid season in
Brazil; higher asthma consultations and hospitalizations
have been reported during this season, especially in
March, compared with the rest of the year in Brazil.
27,28
However, more research is needed to establish the reasons
for differences between individual countries.
Patients with COPD as well as asthma were found to
have a higher mean overall impairment and total work
productivity loss than non-COPD patients. For patients
aged ≥40 years, mean overall impairment and total work
productivity loss both decreased, possibly due to con-
founding (patients still at work aged 40 years or higher
tend to be healthier than the overall patient population of
this age group).
Our study has highlighted the negative emotional
impact that uncontrolled asthma can have on employees
in the workplace and their productivity while at work. A
Canadian study with 300 patients with asthma showed that
over one-third of patients with asthma had psychological
distress (depressive and anxiety symptomatology) as a
comorbidity, and this affected both absenteeism and
presenteeism.
29
Furthermore, lack of asthma control sig-
nificantly correlated with psychological distress, and this
was associated with a higher productivity loss compared
with patients with controlled asthma and no psychologic
distress.
29
Moreover, a larger study in Finland with over
60,000 employees showed that the risk of long-term
permanent work disability is increased in patients with
asthma and depression.
30
A recent cohort study with
160,000 participants showed that psychiatric disorders
were the largest contributing factor of comorbidity costs
to people with asthma, with the greatest economic
impact.
31
This study further contributes to the growing evidence
regarding the burden of poorly controlled asthma on
patients’lives and the wider society. The 2004 Asthma
Insights and Reality global surveys highlighted the inter-
national burden of asthma, with absences noted across
continents; the percentages of adults who lost working
days over a 1-year period due to asthma were 25% in the
United States, 17% in Western Europe, 27% in Asia-
Pacific, and 23% in Central and Eastern Europe.
18
Another recent multinational survey that assessed work
productivity in patients with mild asthma (Global
Initiative for Asthma Steps 1–2) reported an average of
13.3% overall work impairment, which included a 12.5%
rise in impairment due to presenteeism.
32
A recent study from the UK estimated that the cost to
society of work productivity impairment due to poor asthma
control was£6,172 million each year.
33
According to a recent
Canadian study, suboptimal asthma control can lead to a
projected total discounted societal cost of C$213.10 billion
for the period 2014–2033.
34
Another Canadian study also
showed that the cost of comorbidities associated with
asthma, and subsequent productivity impairment, was
approximately C$1,000 per week per individual, with high
comorbidity versus an asthma patient with no comorbidity.
35
Uncontrolled asthma and comorbidities can therefore repre-
sent a significant resource burden.
Predictors for work absence due to respiratory reasons
have been identified, including profession (metal workers
and welders are at higher risk compared with office work-
ers), low forced vital capacity, and occupational exposure
to vapors, gas, dust/fumes and cleaning products, although
it is likely that there are other contributing factors.
36–39
Whilst our study did not specifically address occupational
hazards for employees with asthma, some respondents did
mention the unsuitability of their working conditions.
Employers and human resources personnel should
work with employees to ensure that their workplace is
suitable. An optimal environment may not always be
achievable (eg, creating an allergen-free workplace); how-
ever, it is important to consider that an employee with
severe allergic asthma may require a reduced workload
during pollen season in anticipation of reduced
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productivity during these episodes. Short-term contract
workers should also be given additional flexibility to
work and manage their symptoms with the help of their
healthcare professional and employer.
A key point to note is that most of the asthma patients
who were screened in this survey had symptomatic asthma
despite controller medication. Patients with asthma often
accept their symptoms or overestimate how well their
asthma is controlled.
2
There is a need to continue to
work with patients to gain better control of their disease.
This current study has many strengths; it utilized vali-
dated questionnaires to obtain quantitative and qualitative
data from a large patient sample covering multiple coun-
tries. This study has provided insights into patients with
moderate-to-severe asthma. Despite being an online sur-
vey, a wide age range was sampled, demonstrating that it
is not just younger generations that respond to online
surveys. This study has also re-emphasized the effect
asthma can have on a patient’s daily activities, with over
half of respondents reporting a “prominent”impairment
due to asthma on their regular activities.
There were limitations to the approaches used in this
study. This was a short Internet-based survey rather than a
more in-depth face-to-face or telephone interview, which
might have brought out more information from partici-
pants and minimized missing data.
22
The survey was
translated for each country, but these translations have
not been validated. It also represents only a snapshot
from 1 week of the year for each country, and includes
some subjective qualitative descriptions as well as quanti-
tative data. It is possible that, due to selection bias, people
with socioeconomic, mental or visual impairments may
have been excluded. We were not able to validate their
asthma diagnosis, symptoms or subjective work produc-
tivity. Medication information was based solely on the
information provided by the patient and therefore includes
some uncertainty. We do not have further characteristics of
the people with asthma who were contacted to join the
survey but did not respond, while information as to
whether patients had undergone education on asthma was
also not provided. Furthermore, treatment adherence was
not assessed, so lack of control and other outcomes mea-
sured may be due to poor adherence. However, previous
studies have shown that nearly half of patients with asthma
remain uncontrolled despite maximal adherence.
40
This study highlights the global nature of the problem
and the impact asthma has on work. It is vital that the
asthma community continues to recognize the need for
improved control and more actively assesses how asthma
affects quality of life. It is necessary to raise awareness
that clinicians should be discussing the impact of asthma
on work with their patients. While clinicians tend to ask
how asthma impacts a patients’activities and whether their
job affects their asthma, it is also important to ask patients
how their asthma affects their ability to do their job.
This study contributes to raising awareness of the tan-
gible impact that asthma has, not only on patients, but on
companies and the economy. People with asthma often
accept their symptoms and the impact that they have on
their daily lives. However, clinicians, employers and occu-
pational health teams should be more aware of the impact
of asthma on workers and aim to work toward providing
support solutions. Workplaces may consider offering edu-
cation and strategies to support patients in managing their
tiredness and physical/mental fatigue in order to help
reduce the impact this might have on their productivity
and absence. Workplace wellness programs have seen
benefits from inviting an asthma educator in to proactively
help employees in the workplace.
41
Interventions that
increase adherence to controller therapies have also been
shown to be beneficial.
42
Conclusions
Time spent at work represents a large part of many peo-
ple’s lives, and this study, through personal insights and
quantitative measures, emphasizes the extent to which
work time is adversely affected by asthma in patients
despite the use of long-term maintenance medication.
Around the world, people with asthma report missing
work and struggling with work due to their asthma symp-
toms. Employers and occupational health teams should be
more aware of the impact of asthma on workers.
Furthermore, it is important for clinicians to ask patients
how their asthma affects their ability to do their job and to
discuss strategies to help overcome these challenges.
Abbreviations list
ANOVA, analysis of variance; COPD, chronic obstructive
pulmonary disease; WPAI-SHP, Work Productivity and
Activity Impairment –Specific Health Problem.
Acknowledgments
This study was supported by Boehringer Ingelheim
International GmbH. The authors would like to thank
Katharina Opitz and Valerie Hargreaves for their assis-
tance in the organization and analysis of the survey.
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Kantar Health received funding from Boehringer
Ingelheim International GmbH to conduct the WPAI-SHP
survey. Helen Moore, PhD, at MediTech Media provided
editorial assistance in the development of the manuscript,
funded by Boehringer Ingelheim International GmbH.
Disclosure
KGJ has spoken on behalf of, and worked as a consultant for,
AstraZeneca, Boehringer Ingelheim International GmbH,
Chiesi, GlaxoSmithKline, Mundipharma, Napp, Novartis
and Pfizer, outside the submitted work. MT has received
honoraria from the following companies marketing respiratory
and allergy products: Aerocrine, Boehringer Ingelheim
International GmbH, GlaxoSmithKline, Merck Sharp &
Dohme, Novartis and Pfizer, outside the submitted work; he
is also a member of the BTS/SIGN Asthma guideline steering
group and the NICE Asthma Diagnosis and Monitoring guide-
line development group. MRR reports personal fees from
AstraZeneca, Boehringer Ingelheim International GmbH,
Chiesi, Menarini, Mundipharma, Novartis, Pfizer, Teva and
Bial, and grants and personal fees from GlaxoSmithKline,
outside the submitted work. JMF reports being a member of
advisory boards for AstraZeneca, Boehringer Ingelheim
International GmbH, Novartis, Sanofi-Regeneron, Circassia
and Teva; has been paid honoraria for lecturing at symposia
organized by these companies; and has also undertaken clin-
ical trials through his employer, the University of British
Columbia, for these companies and GlaxoSmithKline.
Funding was also provided to the University of British
Columbia by Boehringer Ingelheim International GmbH dur-
ing the conduct of this study. In the last 5 years IP has received
speaker’s honoraria for speaking at sponsored meetings from
AstraZeneca, Boehringer Ingelheim International GmbH,
Aerocrine, Almirall, Novartis, Teva, Chiesi and
GlaxoSmithKline, and payments for organizing educational
events from AstraZeneca and Teva. He has received honoraria
for attending advisory panels with Genentech, Regeneron,
AstraZeneca, Boehringer Ingelheim International GmbH,
GlaxoSmithKline, Novartis, Teva, Merck, Sanofi, Circassia,
Chiesi and Knopp. He has received sponsorship to attend
international scientific meetings from Boehringer Ingelheim
International GmbH, GlaxoSmithKline, AstraZeneca, Teva
and Chiesi. He has received a grant from Chiesi to support a
phase 2 clinical trial in Oxford. JMH is an employee of
Boehringer Ingelheim International GmbH and UE is an
employee of Boehringer Ingelheim Pharma GmbH & Co.
KG. CV has spoken on behalf of, and worked as a consultant
for, Boehringer Ingelheim International GmbH and Novartis.
The authors report no other conflicts of interest in this work.
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