Medication-related burden and its association with disease severity in Iraqi patients with asthma

Medication-related burden and its association with disease severity in Iraqi patients with asthma Hala Natiq Yahya1, Mohammad Mahmood Mohammed1, Mostafa A. Shafeeq2 1 Department of Clinical Pharmacy, College of Pharmacy, Mustansiriyah University, Baghdad, Iraq 2 Department of Respiratory Diseases, Al-Yarmouk Teaching Hospital, Ministry of Health, Baghdad, Iraq Corresponding author: Hala Natiq Yahya ([email protected]) Received 20 September 2025♦ Accepted 3 November 2025♦ Published 13 November 2025 Citation: Yahya HN, Mohammed MM, Shafeeq MA (2025) Medication-related burden and its association with disease severity in Iraqi patients with asthma. Pharmacia 72: 1–7. https://doi.org/10.3897/pharmacia.72.e172688 Abstract Asthma is a prevalent chronic respiratory condition associated with higher morbidity and mortality among older adults. In Iraq, the prevalence of asthma among adults with a family history is 11.55%. Medication-related burden (MRB) refers to the negative impact of medication regimens on daily life and adherence. Objectives: To assess MRB levels in patients with asthma and examine their association with demographic and clinical variables, as well as disease severity. Methods: purposive cross-sectional study was conducted at two teaching hospitals. Data were collected using a demographic questionnaire and the Living with Medicines Questionnaire to assess MRB. Pulmonary function tests were also performed. Results: The study included 100 patients (mean age 42.9 ± 15.9 years; M:F = 46:54). The MRB distribution was as follows: 55% minimal, 40% moderate, 4% high, and 1% none. Burden was significantly associated with age (P = 0.001163), disease duration (P = 0.03), and disease severity (P = 0.001163). Conclusion: Most patients experienced some degree of MRB, particularly older individuals and those with longer or more severe disease. These findings highlight the importance of addressing medication-related burden in asthma care Keywords Asthma, demographics, Iraq, Living with Medicines Questionnaire, polypharmacy, pulmonary function Introduction Asthma is a prevalent chronic respiratory condition marked by airway inflammation, bronchial hyperreactivity, and fluctuating airflow obstruction, resulting in symptoms such as wheezing, coughing, and chest constriction (Mohammed et al. 2020; Miller et al. 2021; Ramey et al. 2022; Marwan and Mohammed 2023). According to the Global Initiative for Asthma (GINA) and other international guidelines, despite advances in pharmacological management, asthma remains a major global health burden, with outcomes influenced by sociodemographic and environmental factors (Pate 2021; Reddel et al. 2022; WHO 2024). The severity of asthma is determined in many different ways. According to GINA, severity is retrospectively Copyright Yahya HN et al. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Pharmacia 72: 1–7 DOI 10.3897/pharmacia.72.e172688 Research Article Yahya HN et al.: Medication related burden and asthma2 assessed based on the level of treatment required to achieve and maintain control of symptoms and reduce future risk. Mild asthma is controlled with Step 1 or Step 2 treatment, moderate asthma requires Step 3, and severe asthma necessitates Step 4 or Step 5 treatment to prevent uncontrolled symptoms or remains uncontrolled despite this treatment (Louis et al. 2022; GINA 2024; Wu et al. 2025). In Iraq, asthma affects approximately 11.55% of adults, with higher prevalence among older females and those living in urban areas (Salwa et al. 2020; Grant and Wood 2022). These variations highlight the importance of exploring factors beyond clinical severity—such as medication-related burden—which may influence disease control and patients’ quality of life. Medication-related burden (MRB) denotes the physical, mental, and practical difficulties patients encounter in managing their prescriptions, especially in chronic illnesses such as asthma. These burdens may include complex regimens, side effects, financial costs, and psychological stress, all of which can negatively impact adherence. International studies have shown that MRB varies across chronic diseases and is influenced by factors such as polypharmacy, disease severity, and health system support (Mohammed et al. 2018; Mikkola et al. 2025). In asthma care, MRB is especially relevant due to the need for longterm inhaled therapies, frequent dose adjustments, and patient self-management (Agusti et al. 2024). Despite increasing global focus on MRB, there is a significant deficiency in research concerning this topic within the Iraqi asthmatic population. Existing studies in Iraq have focused primarily on prevalence, risk factors, and treatment outcomes, with limited exploration of patient experiences related to medication burden (Jasim et al. 2020; Alsajri et al. 2025). The Living with Medicines Questionnaire (LMQ) is a validated tool for quantifying MRB, with scoring thresholds distinguishing between burden levels: no burden, score 41–73; minimal burden, score 74–106; moderate, score 107–139; high, score 140–172; and extremely high, score 173–205 (Zidan et al. 2018; Katusiime et al. 2024). The research problem addressed in this study is the extent to which medication-related burden affects asthma patients and how this burden correlates with various sociodemographic factors and asthma severity. There is limited local data exploring this association in the Iraqi context, making this study both timely and necessary. The purpose of this study is to assess the level of MRB among patients with asthma and to examine its relationship with age, gender, social and educational status, income, type of residency, and province, as well as asthma severity. Materials and methods Study design and setting This study was a purposive cross-sectional (non-probability sampling) study conducted at the outpatient clinics for respiratory diseases at Al-Yarmouk Teaching Hospital and Al-Imamain Al-Kadhimain Medical City over a period of approximately 8 months. Patients were enrolled based on the following inclusion criteria: adults (both sexes) aged 18–70 years, previously diagnosed with chronic bronchial asthma, and on regular medication for chronic asthma. However, some patients were excluded for having chronic diseases affecting pulmonary function other than asthma, such as chronic obstructive pulmonary disease or interstitial lung disease; for being diagnosed with other comorbid inflammatory disorders; for using chronic oral steroids or medications affecting the inflammatory process; for being current smokers or having a history of smoking within the past 5 years; or for being pregnant or nursing women or individuals with mental disabilities that impair understanding, communication, or willingness to participate. To calculate the sample size, G*Power version 3.1 was used, with 85% power and an alpha level of 0.05. The resulting sample size was 112 (Faul et al. 2007). Data collection Data were collected through direct interviews conducted by the researcher. Each patient was provided with a detailed explanation of the study title, objectives, and methods. All information and test results were kept strictly confidential, and participants were asked to sign informed consent forms before participation. The tool used for data collection was a structured questionnaire comprising two parts: 1. Demographic information: Including age, gender, marital status, income, level of education, type of residency, and province of residence. 2. Living with Medicines Questionnaire (LMQ): Used to assess medication-related burden (Husein and Kadhim 2024). The LMQ contains eight domains: domain 1: “relationships with healthcare professionals” (Questions 7, 14, 20, 24, and 34); domain 2: “practical difficulties in using medicines” (Questions 1, 2, 4, 10, 23, 27, and 29); domain 3: “cost-related burden” (Questions 5, 31, and 33); domain 4: “side effects of medicines” (Questions 21, 22, 30, and 38); domain 5: “effectiveness of prescribed medications” (Questions 3, 15, 25, 32, 39, and 40); domain 6: “concerns about medicines use” (Questions 6, 8, 9, 12, 16, 17, and 18); domain 7: “impact of using medicines on daily life” (Questions 19, 28, 35, 36, 37, and 41); and domain 8: “autonomy to vary regimen” (Questions 11, 13, and 26). Higher scores indicate more negative experiences with medications (i.e., higher medication-related burden). Responses were scored as follows: strongly agree = 5, agree = 4, disagree = 2, and strongly disagree = 1. Reverse scoring (strongly agree = 1, agree = 2, disagree = 4, and strongly disagree = 5) was applied where appropriate (Questions 3, 4, 7, 11, 13, 14, 15, 20, 24, 25, 26, 27, 32, 34, 39, and 40). According to the total score of Pharmacia 72: 1–7 3 these 41 questions, medication-related burden was classified as follows: no burden, score 41–73; minimal burden, score 74–106; moderate burden, score 107–139; high burden, score 140–172; and extremely high burden, score 173–205 (Zidan et al. 2018). The LMQ was translated into Arabic, and a pilot study was conducted among 20 patients. The translated version was evaluated by five expert physicians and clinical pharmacists before conducting the main study. The Arabic version of the LMQ showed good reliability and stability, with Cronbach’s alpha coefficient = 0.71. Pulmonary function testing After completion of the questionnaire, pulmonary function tests (PFTs) were performed for each patient to measure: • Forced expiratory volume in 1 second (FEV₁) • Forced vital capacity (FVC) • FEV₁/FVC ratio Based on the results and the judgment of a respiratory disease specialist, patients were categorized as having mild, moderate, or severe asthma according to the Global Initiative for Asthma (Bradley et al. 2022; GINA 2024; Wu et al. 2025). Statistical analysis The Statistical Package for the Social Sciences (SPSS) version 22 software was used for analysis and representation of the study data. The independent t-test and one-way ANOVA were used to examine the level of significance among the study variables. The level of significance was set at P ≤ 0.05. Ethical approval statement Approval from the Ministry of Higher Education and the Scientific Ethics Committee of Mustansiriyah University – College of Pharmacy (Approval No. 78-91/2024) was obtained. Additional approvals from the Ministry of Health, Al-Karkh Health Directorate, Al-Yarmouk Teaching Hospital, and Al-Imamain Al-Kadhimain Medical City were also secured. Before participating in the study, all patients provided informed consent. Participants were clearly informed that the study was conducted solely for scientific and research purposes. They were assured that all information, whether personal or medical, would remain confidential and would be used only in accordance with ethical research standards. All procedures were conducted in compliance with the ethical principles outlined in the Declaration of Helsinki. Results A total of 100 patients were enrolled in this study. The mean age was 42.87 ± 15.85 years, with 66% aged ≤ 50 years and 34% aged > 50 years (Fig. 1A). The maleto-female ratio was 46:54 (Fig. 1B). Regarding marital status, 23% were single, 65% married, 2% divorced, and 10% widowed (Fig. 1C). In terms of educational level, 6% were illiterate, 35% had completed primary school, 36% secondary school, and 23% held a bachelor’s degree (Fig. 1D). With respect to monthly income, 51% reported earning less than 500,000 Iraqi dinars (ID), 37% between 500,000 and 1,000,000 ID, and 12% more than 1,000,000 ID (Fig. 1E). Most patients (92%) resided in urban areas, while 8% lived in rural areas (Fig. 1F). Geographically, 94% were from Baghdad (the capital), while 2% each were from Thi Qar and Wasit, and 1% each from Babil and Diyala provinces (Fig. 1G). All the above are clarified in Table 2. Only 1% of the patients reported no medication burden, while 55%, 40%, and 4% experienced minimal, moderate, and high burdens, respectively, according to the Living with Medicines Questionnaire (LMQ) score (Table 1). The mean medication burden score was 105.83 ± 18.793 for males and 102.41 ± 15.755 for females, with no statistically significant difference (P = 0.246). Significant differences were observed in mean scores based on age: patients aged ≤ 50 years had a mean score of 106.67 ± 19.102, whereas those > 50 years had a mean score of 98.76 ± 11.309 (P = 0.001). No significant differences were found in medication burden scores across marital status groups (P = 0.483), with mean scores of 108.87 ± 17.553, 102.42 ± 17.701, 112.34 ± 33.94, and 101.30 ± 7.025 among single, married, divorced, and widowed patients, respectively. Regarding income, the mean scores were 104.96 ± 16.194, 104.76 ± 18.661, and 97.42 ± 16.790 for participants earning less than 500,000 IQD, between 500,000 and 1,000,000 IQD, and more than 1,000,000 IQD, respectively, with no significant variation (P = 0.187). Educational-level groups showed mean scores of 110.67 ± 14.61 (illiterate), 99.40 ± 13.819 (primary), 105.64 ± 19.757 (secondary), and 106.61 ± 17.653 (bachelor’s degree), with no significant differences (P = 0.623). No significant differences were found between urban and rural residents, with mean scores of 103.97 ± 17.064 and 104.13 ± 20.145, respectively (P = 0.483). Similarly, no significant differences were observed among patients from Babil, Baghdad, Diyala, Thi Qar, and Wasit provinces (P = 0.865) (Table 2). Table 1. Patients’ distribution according to medication-related burden level (LMQ score). MRB level N (%) LMQ score (Mean ± SD) No burden 1 (1%) 73 ± 0 Minimum burden 55 (55%) 91.82 ± 7.751 Moderate burden 40 (40%) 117.60 ± 9.007 High burden 4 (4%) 142.75 ± 11.587 N: number; %: percent; SD: standard deviation; LMQ: Living with Medicines Questionnaire. Yahya HN et al.: Medication related burden and asthma4 No significant difference was found between the mean medication burden scores of patients with ≤ 1 chronic disease (104.57 ± 17.935) and those with > 1 chronic disease (101.47 ± 13.935) (P = 0.484). Similarly, the mean scores were 104.16 ± 17.355 and 98.00 ± 12.490 among patients taking ≤ 3 and > 3 chronic medications, respectively, with no significant difference (P = 0.544). However, a significant difference was observed regarding disease duration: patients with disease duration ≤ 10 years had a lower mean score (101.37 ± 15.965) compared to those with duration > 10 years (109.27 ± 18.655) (P = 0.03). These findings are summarized in Table 3. The association between medication-related burden (MRB) level and disease severity was significant (P = 0.027) based on a one-way ANOVA test. Among the patients, 69% had mild asthma, 12% had moderate asthma, and 19% had severe asthma. These results are presented in Table 4. A post hoc multiple comparison test was conducted to determine which specific groups differed significantly, and the results showed that the burden level was significantly different only between patients with mild and severe asthma (P = 0.045) (Table 5). Figure 1. Patients’ sociodemographic distribution. *% = percent; IQD = Iraqi dinar. Pharmacia 72: 1–7 5 Discussion The study’s results revealed that only 1% of patients reported no medication-related burden (MRB), while 55%, 40%, and 4% experienced minimal, moderate, and high levels of burden, respectively. These results agree with a previous study conducted among hemodialysis patients in Baghdad hospitals (Baghdad Medical City and Al-Karama Teaching Hospital), where MRB levels were 57.5% minimal, 41.5% moderate, and 1% high (Husein and Kadhim 2024). Similarly, our findings align with a study conducted in Qatar (Kassa et al. 2020), which also reported comparable MRB distribution. Conversely, this study’s results differ from those of another study conducted among 423 systematically selected diabetic patients attending the diabetes clinic at Felege Hiwot Comprehensive Specialized Hospital (FHCSH) between June and August 2020. In that study, 58.9% of patients experienced a moderate burden and 26.2% a high burden (Bekalu et al. 2022). These discrepancies may be attributed to differences in study populations, particularly in the number, types, and routes of medication administration. Importantly, while the current study focused on asthma patients, direct comparisons with asthma-specific MRB research are limited. However, a systematic literature review conducted in the United States, the United Kingdom, Germany, France, Italy, Spain, Canada, Japan, and Australia focused on the impact of moderate-to-severe asthma and found that asthma patients frequently reported medication-related problems, including difficulties with inhaler use, adherence, and understanding medication instructions (Czira et al. 2022). Additionally, a U.S.-based study highlighted cost-related non-adherence among adults with asthma, linking financial hardship to increased MRB and poorer asthma control (Hung et al. 2023). These findings suggest that MRB in asthma may be influenced not only by medication complexity but also by socioeconomic factors and healthcare system support. Furthermore, the present study found no significant association between MRB and demographic variables such as gender, marital status, income, educational level, or place of residence. However, age was significantly associated with MRB, with patients aged ≤ 50 years reporting higher levels of burden compared to those > 50 years. These findings are in agreement with the earlier hemodialysis study regarding gender, marital status, income, and education, but differ in terms of age. In that study, age was not significantly associated with MRB, which could be due to differences in the studied populations and the age ranges analyzed (Husein and Kadhim 2024). Table 2. Effect of patients’ sociodemographic characteristics on medication burden according to the total LMQ score. Characteristics Subcategory N (%) LMQ score (Mean ± SD) P value Age (years) ≤ 50 years 66 (66) 106.67 ± 19.102 0.001163 a > 50years 34 (34) 98.76 ± 11.309 Gender Male 46 (46) 105.83 ± 18.793 0.246 a Female 54 (54) 102.41 ± 15.755 Social status Single 23 (23) 108.87 ± 17.553 0.483 b Married 65 (65) 102.42 ± 17.701 Divorced 2 (2) 112 ± 33.941 Widow 10 (10) 101.3 ± 7.025 Educational level Illiterate 6 (6) 110.67 ± 14.61 0.623 b Primary school 35 (35) 99.4 ± 13.819 Secondary school 36 (36) 105.64 ± 19.757 Bachelor 23 (23) 106.61 ± 17.653 Monthly income < 0.5 million IQD 51 (51) 104.96 ± 16.194 0.187 b 0.5–1.0 million IQD 37 (37) 104.76 ± 18.661 > 1.0 million IQD 12 (12) 97.42 ± 16.790 Residency Urban 92 (92) 103.97 ± 17.064 0.483 a Rural 8 (8) 104.13 ± 20.145 Province Babil 1 (1) 113 ± 0 0.865 b Baghdad 94 (94) 104.62 ± 17.239 Diala 1 (1) 86 ± 0 Thee Kaar 2 (2) 94 ± 24.042 Wasit 2 (2) 88 ± 0.707 N: number; %: percentage; SD: standard deviation; IQD: Iraqi dinar (1 million = 700 USD); LMQ: Living with Medicines Questionnaire. a Independent t-test. b One-way AVOVA. Table 3. Effect of patients’ clinical characteristics on medication burden according to the total LMQ score. Characteristics Subcategory N (%) LMQ score (Mean ± SD) P value Number of chronic diseases ≤ 1 81 (81) 104.57 ± 17.935 0.484 > 1 19 (19) 101.47 ± 13.935 Number of chronic medications ≤ 3 97 (97) 104.16 ± 17.355 0.544 > 3 3 (3) 98 ± 12.490 Disease duration(years) ≤ 10 67 (67) 101.37 ± 15.965 0.03 >10 33 (33) 109.27 ± 18.655 N: number; %: percentage; SD: standard deviation; LMQ: Living with Medicines Questionnaire. Independent t-test. Table 4. The association between medication-related burden and disease severity. Disease severity Medication related burden N (%) LMQ score (Mean ± SD) P value Mild 69 (69) 100.91 ± 16.824 0.027 Moderate 12 (12) 111.25 ± 19.832 Severe 19 (19) 110.53 ± 14.273 Total 100 (100) 103.98 ± 17.215 N: number, %: percentage, SD: Standard deviation. One-way AVOVA. Table 5. Post hoc multiple comparison test (Tukey honestly significant difference). (I) disease severity (J) disease severity Mean difference (I-J) SE P value Mild Moderate –10.873 5.053 0.085 Mild Severe –10.150 4.186 0.045 Moderate Severe 0.724 5.957 0.992 SE = standard error. Yahya HN et al.: Medication related burden and asthma6 In addition, the current study’s results concur with those of the diabetic-patient study regarding the lack of significant association between MRB and both educational level and place of residence (Bekalu et al. 2022). Notably, no significant associations were observed between MRB and either the number of chronic diseases or the number of chronic medications. However, a significant association was found with disease duration: patients with a disease duration of more than 10 years reported a higher burden than those with a duration of 10 years or less. These findings agree with those of the hemodialysis-patient study in terms of the number of medications and disease duration but differ regarding the number of chronic diseases, which showed a significant association with MRB in the hemodialysis population but not in the current study (Husein and Kadhim 2024). Finally, international studies have emphasized the role of healthcare system structure in shaping MRB. For example, countries with robust asthma-education programs and multidisciplinary care teams—such as the UK and Germany—report lower MRB levels among asthma patients, suggesting that system-level interventions may mitigate burden and improve adherence (Nunes et al. 2017; Jacobs et al. 2023). Limitation of the study • The first limitation was the sample size (100 patients only), which may not be representative of the broader population. As a result, the extent to which these findings can be applied to other demographic groups is limited. Future research should aim to include a larger and more diverse sample to enhance external validity. • The second limitation was the study’s reliance on self-reported data, which may have been affected by recall bias or social desirability bias. This could influence the authenticity of the responses. Future studies could incorporate observational methods or triangulate data sources to strengthen reliability. Conclusion This study provides further evidence regarding the levels of medication-related burden (MRB) and associated factors in patients with asthma. In this study, the main factors affecting MRB were age, disease duration, and disease severity. MRB among Iraqi patients with asthma was lower among those younger than 50 years, with a disease duration of less than 10 years, and those with mild disease severity. The current study highlights the need for healthcare providers to recognize and address MRB as an integral component of asthma management. They should simplify treatment plans, offer counseling to enhance adherence, and regularly assess MRB. At the healthcare system level, integrating MRB assessment tools such as the Living with Medicines Questionnaire into routine practice could support more holistic and efficient care. Acknowledgements The authors wish to express their sincere gratitude to the management of Al-Yarmouk Teaching Hospital, Al-Imamain Al-Kadhimain Medical City, and Baghdad Al-Karkh Health Directorate for their generous support and cooperation throughout the course of this research. Special thanks are extended to the dedicated medical and nursing staff of the Respiratory Diseases Clinic and the Pulmonary Function Testing Unit for their professionalism and valuable assistance during data collection and patient coordination. The researchers are also deeply grateful to Dr. Belal Yaseen Ibraheem, Community Medicine Specialist at the Al-Karkh Health Directorate, whose expert guidance, constructive feedback, and continuous encouragement had a significant impact on the quality and completion of this study. The success of this research would not have been possible without the contributions of all these individuals and institutions, and the researchers are truly appreciative of their efforts. Additional information Conflict of interest The authors have declared that no competing interests exist. Ethical statements The authors declared that no clinical trials were used in the present study. The authors declared that no experiments on humans or human tissues were performed for the present study. Informed consent from the humans, donors or donors’ representatives: Iraqi ministry of health/Al-Yarmouk teaching hospital and AL-Immamain AL-Khadmain teaching hospital The authors declared that no experiments on animals were performed for the present study. The authors declared that no commercially available immortalised human and animal cell lines were used in the present study. Use of AI No use of AI was reported. Funding This research was supported by Al-Yarmouk Teaching Hospital, Al-Imamain Al-Kadhimain Medical City, and Baghdad AlKarkh Health Directorate. Author contributions All authors have contributed equally. Author ORCIDs Hala Natiq Yahya https://orcid.org/0009-0003-4995-9423 Mohammad Mahmood Mohammed https://orcid.org/00000002-1205-4829 Mostafa A. Shafeeq https://orcid.org/0009-0006-5258-5161 Data availability All of the data that support the findings of this study are available in the main text. Pharmacia 72: 1–7 7 References Agusti A, Bel E, Thomas M, et al. (2024) The value of treatable traits across the spectrum of adult asthma severity. The Journal of Allergy and Clinical Immunology: In Practice 12(4): 1001–1012. https:// www.jaci-inpractice.org/article/S2213-2198(24)00072-2/fulltext Bekalu AF, Yenit MK, Tekile MT, Birarra MK (2022) Medication-related burden and associated factors among diabetes mellitus patients at Felege Hiwot Comprehensive Specialized Hospital in northwest Ethiopia. Frontiers in Clinical Diabetes and Healthcare 3: 977216. https:// doi.org/10.3389/fcdhc.2022.977216 Czira A, Turner M, Martin A, Hinds D, Birch H, Gardiner F, Zhang S (2022) A systematic literature review of burden of illness in adults with uncontrolled moderate/severe asthma. Respiratory Medicine 191: 106670. https://doi.org/10.1016/j.rmed.2021.106670 Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods 39: 175–191. https:// doi.org/10.3758/BF03193146 GINA [Global Initiative for Asthma] (2024) Global Strategy for Asthma Management and Prevention, 2024. https://ginasthma.org/2024-report/ Hung LC, Patel M, Bryant-Stephens T, et al. (2023) Cost-related medication nonadherence among adults with asthma: A national survey analysis. The Journal of Allergy and Clinical Immunology: In Practice 11(1): 112–120. https://doi.org/10.1136/thorax-2024-221778 Husein SA, Kadhim DJ (2024) Medication-related burden among Iraqi hemodialysis patients. Farmacia 72(2): 356–364. https://doi. org/10.31925/farmacia.2024.2.23 Jacobs A, Wu R, Tomini F, De Simoni A, Mihaylova B (2023) Strong and graded associations between level of asthma severity and all-cause hospital care use and costs in the UK. BMJ Open Respir Res. 10(1): e002003. https://doi.org/10.1136/bmjresp-2023-002003 Jasim AL, Saleh ES, Abd Ali MN (2020) Assessing the response of a sample of Iraqi asthmatic patients to different medication regimens. Medico-Legal Update. 20(3): 1552. https://doi.org/10.37506/mlu.v20i3.1552 Kassa DA, Mekonnen S, Kebede A, Haile TG (2020) Cost of hemodialysis treatment and associated factors among end-stage renal disease patients at tertiary hospitals of Addis Ababa city and Amhara region, Ethiopia. ClinicoEconomics and Outcomes Research 12: 399–409. https://doi.org/10.2147/CEOR.S256947 Louis R, Satia I, Ojanguren I, Valero A, Rigau D, Roche N, Chanez P (2022) European Respiratory Society guidelines for the diagnosis of asthma in adults. European Respiratory Journal 59: 2101585. https:// doi.org/10.1183/13993003.01585-2021 Marwan S, Mohammed M (2023) Effect of pharmacist interventions on pulmonary function parameters of Iraqi asthmatic patients: a comparative study. Iraqi Journal of Pharmaceutical Sciences 32(2): 9–17. https://doi.org/10.31351/vol32iss2pp9-17 Mikkola H, Aarnio E, Hämeen-Anttila K, Airaksinen M, Dimitrow M, Saastamoinen L (2025) Medication-related burden variation across chronic conditions: a population-based cross-sectional survey. BMC Health Serv Res. 25: 1283. https://doi.org/10.1186/s12913-02513402-4 Miller RL, Grayson MH, Strothman K (2021) Advances in asthma: new understandings of asthma’s natural history, risk factors, underlying mechanisms, and clinical management. Journal of Allergy and Clinical Immunology 148: 1430–1441. https://doi.org/10.1016/j.jaci.2021.10.001 Mohammed M, Abbas N, Rashid A (2020) Estimating the knowledge and attitude of parents about their children’s asthma and evaluating the impact of their education status in Baghdad, Iraq. Systematic Reviews in Pharmacy 11(8): 594–599. Mohammed MA, Moles RJ, Hilmer SN, O’Donnell LK, Chen TF (2018) Development and validation of an instrument for measuring the burden of medicine on functioning and well-being: the Medication-Related Burden Quality of Life (MRB-QoL) tool. BMJ Open 8: e018880. https://doi.org/10.1136/bmjopen-2017-018880 Nunes C, Pereira AM, Morais-Almeida M (2017) Asthma costs and social impact. Asthma Research and Practice 3(1): 1. https://doi. org/10.1186/s40733-016-0029-3 Pate CA (2021) Asthma surveillance—United States, 2006–2018. Morbidity and Mortality Weekly Report Surveillance Summaries 70: 1–29. https://doi.org/10.15585/mmwr.ss7005a1 Ramey OL, Almodóvar AS, Nahata MC (2022) Medication adherence in Medicare-enrolled older adults with asthma before and during the coronavirus disease 2019 pandemic. Annals of Allergy, Asthma & Immunology 128: 561–567. https://doi.org/10.1016/j.anai.2022.01.018 Reddel HK, Bacharier LB, Bateman ED, Brightling CE, Brusselle GG, Buhl R, Cruz AA, Duijts L, Drazen JM, FitzGerald JM, Fleming L, Inoue H, Israel E, Kaplan A, Khurana A, Krishnan JA, Levy ML, Lin J, Martinez FD, Peters MJ, Sheikh A, Spector SL, Szefler SJ, Vanker A, Zar HJ, Boulet LP (2022) Global initiative for asthma strategy 2021: executive summary and rationale for key changes. American Journal of Respiratory and Critical Care Medicine 205: 17–35. https://doi. org/10.1164/rccm.202109-2205PP Salwa GT, Ali HA, Suad AB, Mohammed RA (2020) Allergen profile of rhinitis and asthma among Iraqi patients. Clinical Epidemiology and Global Health 8(2): 437–442. https://doi.org/10.1016/j. cegh.2019.12.018 WHO [World Health Organization] (2024) Asthma: treatment. World Health Organization. https://www.who.int/news-room/fact-sheets/ detail/asthma Wu W, McDonald V, Wang G, Gibson P (2025) The value of treatable traits across the spectrum of adult asthma severity. Chinese Medical Journal Pulmonary and Critical Care Medicine. https://doi. org/10.1016/j.pccm.2025.08.002 Zidan A, Awaisu A, El-Hajj MS, Al-Abdulla SA, Figueroa DCR, Kheir N (2018) Medication-Related Burden among Patients with Chronic Disease Conditions: Perspectives of Patients Attending Non-Communicable Disease Clinics in a Primary Healthcare Setting in Qatar. Pharmacy 6(3): 1–10. https://doi.org/10.3390/pharmacy6030085