In a pediatric asthma patient on inhaled corticosteroids and short‑acting β2‑agonist (salbutamol) with recurrent emergency‑room visits due to incorrect inhaler technique and lack of education, which term best describes the situation: increase self‑efficacy, decrease hospitalization, or increase adverse effects?

Defining the Clinical Situation: Lack of Self-Efficacy Leading to Persistent Emergency Visits

The situation described is best characterized as a failure to increase self-efficacy (Option A), which directly causes the persistent emergency room visits despite appropriate medication availability. This pediatric patient has the correct medications (ICS and salbutamol) but lacks the knowledge and skills to use them properly, representing a fundamental breakdown in asthma self-management education 1.

Why This Represents a Self-Efficacy Problem

Self-efficacy—the patient and family's confidence and ability to manage asthma independently—is the core deficit here. The evidence demonstrates that:

• Self-management education, including proper inhaler technique instruction and written action plans, reduces hospitalizations, emergency room visits, unscheduled doctor visits, and days off school 1
• When physicians are trained to teach inhaler technique and provide self-management education, children have significantly fewer hospitalizations and emergency room attendances 1
• The strongest evidence shows self-management works best when it includes written asthma action plans and verified inhaler technique 1

Why This Is NOT About Decreasing Hospitalization (Option B)

The question asks what defines the situation, not the desired outcome. The situation is characterized by inadequate education and skill-building, not by the hospitalization rate itself. Decreased hospitalization is the outcome we seek by addressing the self-efficacy problem, not the problem itself 1.

Why This Is NOT About Adverse Effects (Option C)

Incorrect inhaler technique typically results in under-dosing rather than adverse effects. When patients use inhalers incorrectly:

• Most children under 5 cannot coordinate unmodified MDIs properly and require large volume spacers with face masks 2
• Poor technique leads to inadequate drug delivery to the airways, causing treatment failure and continued exacerbations 2, 3
• The medications themselves (ICS and salbutamol) have excellent safety profiles when used correctly 4, 5

The Clinical Algorithm for This Situation

When a pediatric asthma patient has recurrent ER visits despite prescribed controller and rescue therapy, systematically verify:

1. Inhaler technique assessment - Directly observe the patient/family demonstrating inhaler use; most treatment failures stem from technique errors 2, 3

2. Device appropriateness - Confirm age-appropriate delivery devices (spacers with masks for young children) 2

3. Written action plan provision - Ensure family has clear instructions on when to increase treatment and when to seek emergency care 1

4. Medication adherence verification - Distinguish between inability to use inhalers correctly versus non-adherence to the regimen 1

Common Pitfalls in This Scenario

The physician's assumption that prescribing medications equals effective treatment is the critical error. The evidence shows:

• Patients can be taught to become more effective partners in consultations through structured education, dramatically improving compliance and health outcomes 1
• Teaching patients how to present symptoms clearly and question their doctor improves satisfaction and adherence 1
• Giving patients control of their condition through education and action plans is more effective than simply prescribing medications 1

The Solution Framework

To address this self-efficacy deficit:

• Provide face-to-face inhaler technique demonstration and have the family demonstrate back to you 2, 3
• Supply a written asthma action plan with specific PEF thresholds and medication adjustments 1
• Schedule follow-up within 1 week to reassess technique and reinforce education 1, 2
• Consider referral to asthma educators or respiratory specialists if technique problems persist 1, 3

The fundamental issue is that this family lacks the knowledge, skills, and confidence (self-efficacy) to manage asthma at home, making Option A the correct answer.