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Psychological factors may have a significant impact on attitudes to disease and medications, on the ability to work with health professionals and to comply with management regimens . Psychological status is also associated with reported respiratory symptoms, independent of pulmonary function . However, the impact of adverse psychological factors may be more subtle and insidious. Such factors have a negative impact on the acquisition of self-management knowledge and on self-management behaviour as well as being associated with serious self-management errors . For educational initiatives to be maximally effective, these factors need to be identified and acknowledged, and management strategies need to be adjusted accordingly.