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A variety of psychological, health-care and socioeconomic factors had powerful and differential influences on self-management knowledge and behaviour (Figure 2). However, there was encouraging evidence that the factors associated with appropriate educational initiatives and good quality of ongoing medical care were positively associated with both knowledge and behaviour scores, providing support for current asthma educational initiatives. Self-management errors: Despite the widespread use of asthma education, patients commonly make serious selfmanagement errors during an acute attack, including no or delayed use of oral corticosteroids and/or no or delayed summoning of emergency services . Errors are generally made by the patient rather than the doctor, and may be predicted by a variety of adverse socioeconomic and psychological factors . These factors may so totally dominate and overwhelm the individual so as to nullify the potentially positive influences of asthma education. This is consistent with the hierarchical principle of behaviour change in education, in which there is a natural order in the sequence of factors influencing behaviour. Unless the most pressing psychological issues, and financial and practical concerns of patients are addressed, an educational initiative is unlikely to be beneficial. However, errors were not predicted by the level of self-management knowledge , suggesting that such errors may not be avoided by conventional asthma selfmanagement education. Because most severe attacks leading to hospitalization are theoretically preventable, the challenge is to change patient behaviour in the face of these adverse socioeconomic and psychological factors. Figure 2) Influences on self-management knowledge and behaviour. MDI Metered dose inhaler; PEF Peak expiratory flow; PFM Peak flow meter. Reproduced with permission from reference 10