The core category "A functional day as desired by the person" was described as having a normal life, which included expectations of being able to manage anything a person without asthma could. Various examples were given, such as physical activities both in terms of exercise and daily activities like climbing the stairs or running for a bus, but also being able to burst into laughter without experiencing symptoms. In brief, an everyday life in which the asthma did not show its face. Most of them reported having achieved a desired functional day. However, it was evident that some of the participants experienced restrictions in relation to certain physical activities, yet they perceived their everyday life with asthma as satisfactory. This perception could be explained by the comparisons they made between today's asthma function and previous function during childhood, when the asthma was experienced as much severer. A functional day seemed to regulate efforts to achieve this outcome.
As illustrated in Figure 1, three types of regulatory foci were identified: Promotive, Preventive and Permissive, which regulated three types of medication tactics: Approaching illness control, Avoiding uncontrolled illness and Acting on the spur of symptoms.
This focus was characterized by an eagerness to strive for a positive asthma outcome. This thinking stemmed from a strong wish to live a life equal to that of persons without asthma. Participants associated with this focus aspired to accomplish all of the important things in life without being disturbed by the asthma. Therefore a promotive focus was aimed at progressing with the medication tactic to attain a functional day.
Asthma playing in the background
When the asthma was playing in the background, no signs of illness were present in everyday life. The asthma did not interfere with activities in daily life, which allowed the participants to do things that played an important role in their social life. Another advantage of having asthma in control was the possibility to manage other daily activities without experiencing restrictions.
"It means that I, for example, have the energy to climb the stairs much more easily than I would without medication. Without standing and panting afterwards and feeling the tightness and all. Or when I run to the bus when I'm about to miss it. Things like that." (4)
Approaching controlled illness
Promotive adherence reasoning
This reasoning was influenced by the aspiration to achieve a functional day. Adhering to the asthma medication prescription was thus viewed as advancement towards this ideal state when the asthma only plays in the background. Some medication worries were put forward, but the benefits seemed to exceed the concerns. It was argued that this medication tactic was considered promising because it was expected to promote a preferred lifestyle.
"You want to do exercise, for example, because that's important for your body. So you get to take a little medicine so you can manage it. Anyway it's a good reason to take medicine. It's great. So then you take it to feel good." (7)
Participants who had adopted this type of adherence behaviour had noted that it generated a positive outcome reflected in an asthma day that was easily managed. When they had found themselves between prescriptions, they had experienced episodes during which the desired outcome had not been attained. Such experiences were used as opportunities to compare periods when the asthma was playing in the background with periods when the asthma was showing its face. Eventually, these experiences seemed to function as evidence of the gains associated with their present medication tactic.
"It's because I know it makes me feel better. I have tested, for example, when I've run out of medicine and not received the new prescription yet. So I've been without it a while and I simply notice the difference in how I feel. So that's why I'm careful with it, because I know I feel better and that everyday life is easier for me. Well, that's the simple reason." (4)
Promotive medication adjustment
This medication tactic was aimed at achieving a desired asthma outcome by using a minimum of asthma medication. Thus, medication use was adjusted depending on estimated need without jeopardizing a positive outcome. One advantage of this strategy was that the body was not exposed to medication unnecessarily, while no clear concerns about side effects were expressed. This tactic rested on the opinion that every person knows best how his/her own body functions - even better than the doctors who made their assessment during a short clinical visit, sometimes without performing medical tests. This thinking led to medication breaks of varying duration. Some had been off medication for almost a year, but were still able achieve a functional day. Others had shorter breaks, for instance during stays abroad for a couple of weeks to several months when the asthma was perceived to function satisfactorily without medication.
"So I don't really follow the doctor's orders to the letter, instead I have a feeling for what's needed. And if I'm just .... going on a trip for two weeks then I don't need to take it just because I'm travelling." (14)
Shorter breaks during periods requiring less physical exertion also occurred. It was stressed that this strategy was not recommended for persons newly diagnosed with asthma, because it required experience. It was also expressed that one risk associated with this strategy is that one could unconsciously get used to poorer asthma function.
This focus was grounded in a sense of responsibility one had to oneself to be spared from a situation in which the asthma dominated everyday life. Participants associated with this focus tended to act in an anticipatory way to keep the signs of illness away. This thinking was shown in their adherence behaviour, which was motivated by the need to ensure that asthma would not play in the foreground.
Asthma playing in the foreground
When the asthma played in the foreground, it showed its face as typical asthma symptoms. These episodes varied in length and severity, but were perceived as a direct consequence of not having taken the asthma medication as usual.
"Then my voice gets hoarse. It can be a little tough when I wake up, sometimes breast pain when I breath and I feel ... so I lose my voice often and at times it's hard to talk and I'm clearing my voice all the time, that's what happens. I don't feel quite as alert either." (1)
It was not only the occurrence of symptoms that was experienced as troublesome when the asthma set the agenda, but also its effect on daily life as a whole. Such a period was described as being characterized by poor strength and difficulty managing ordinary physical activities like climbing the stairs. An insufficient ability to stay focused that negatively affected their work or studies was also described.
Avoiding uncontrolled illness
Preventive adherence reasoning
This medication tactic was aimed at avoiding being controlled by the asthma. Simultaneously, it was expected to secure a functional day. Taking the asthma medication as recommended was therefore considered both as a necessary investment and as an essential tactic. Despite a few concerns with intake of asthma medication, this medication tactic was regarded as a precautionary measure that was believed to prevent the asthma from playing in the foreground, both at present and in the future.
"... I take them because I know I won't feel well if I don't take them. So somewhere in the back of my mind there's something saying I have to take them in order to get through the day." (15)
"It may get worse in the future ... if I don't take my medicine now, I probably won't feel good in the future, and I think about that." (1)
It was also argued that this tactic had spared them from severe asthma attacks in the past. Some participants had experienced troublesome asthma attacks that had etched fearful memories in their minds. These were incidents they never wanted to relive again. Some even expressed worries about not currently having a sufficient medication treatment, despite claiming to experience a functional day. Others knew about other people's asthma mismanagement and concomitant severe attacks. Thus, taken together, these experiences functioned as cautionary examples that influenced their current adherence behaviour.
It was explained that managing asthma through preventive adherence behaviour had an overall advantage in terms of the sense of calm that grows out of being certain one is safe.
"Well, then it's like you take it to feel ... feel secure and protected. You don't have to feel bad as often." (11)
Preventive medication overuse
Another preventive medication tactic was to overuse the asthma medication. This tactic seemed to be associated with distrust that the current prescription of asthma medication provided comprehensive protection from a negative asthma outcome. Preventive overuse was deliberately put into practice as an additional guarantee that the asthma would have no opportunity to play in the foreground. In these cases, the asthma was considered a very troublesome disease and a watchful eye was constantly kept on possible emerging asthma symptoms. This tactic was manifested by taking both the preventive and reliever asthma medication more times a day than was prescribed.
"I'm supposed to take my preventer inhaler daily, morning and evening, but sometimes I take it several times a day. Along with my rescue inhaler." (8)
Yet another type of preventive overuse was described that only involved the reliever medication. It was regarded as a required preventive measure to make sure that the asthma would not play in the foreground, for example when performing strenuous physical activities. The experience of side effects such as tremor and palpitations was thought to be a worthwhile investment given the benefit of this protective medication tactic.
This focus was aligned with a kind of "let-it-go" mentality, according to which everything will turn out fine. Some skeptical voices towards intake of asthma medication were raised, but they were not heard in general. Participants associated with this way of thinking gave the expression of being rather indifferent in relation to asthma and its outcome. Despite the fact that they had experienced severe attacks, they acted as if their everyday life was seemingly unaffected by asthma. They vaguely described a desired asthma outcome as being relieved from emerging symptoms.
Asthma playing out of earshot
The asthma was explained as something that was included in the participants' daily life and that they did not pay much attention to. One good reason was that asthma was given low priority due to another, more troublesome disease. Another was that the accuracy of the asthma diagnosis was doubted. It was argued that asthma symptoms could just as well be experienced by all people, even those without an asthma diagnosis. There was an obvious paradox in these lines of reasoning, as being completely without asthma medication was not an option.
"Of course I want the rescue inhaler - I don't want to get rid of that. ... ... but maybe even people in general sometimes have trouble breathing ... I don't know what's normal." (10)
Acting on the spur of symptoms
Permissive adherence reasoning
This medication tactic was justified by the explanation that the participants' asthma mostly was playing out of earshot. However, when the symptoms became more pronounced, they triggered the intake of asthma medication. Although these participants described their medication tactic as not recommendable, they seemed unmotivated to change tactics. No benefit of this medication tactic was expressed. Instead it was put forward that regular medication behaviour would be more advantageous. Still, they reported not really wanting to change their medication tactics.
"I don't think I'll change anything, I'll just keep doing what I do now or .... although it would probably be good to develop a routine for this. But I don't think I'll do anything about it." (13)
Unstructured medication use
Participants associated with a permissive focus had no integrated routines for their medication intake. They seldom prepared themselves before contact with known asthma triggers, meaning that they did not act until the asthma was playing within earshot. Consequently, they reported unstructured adherence behaviour, implying that the asthma medication was not taken regularly.
"No, it feels like it's been a long time since I was good at taking the preventer inhaler so I really don't know. No, I don't know. I'm really bad about taking my medications, that's all." (10)
Sometimes the medication was taken according to prescription, then it was not taken at all for a few weeks or even longer periods. Still the asthma function was experienced as satisfactory, on the whole.