Factors associated with uncontrolled asthma among Sudanese adult patients

INTRODUCTION

Asthma constitutes a significant public health problem and its burden is high in both developed and developing countries. Recent estimates suggest that 358 million people globally have asthma and the prevalence has increased by 12.6% in 2015 compared to 1990.^[1] There will be an additional 100 million people with asthma by 2025, mostly due to the projected increase in urban population. In Khartoum, the capital of Sudan, asthma prevalence ranged from 12.5% in children^[2] to 10.8% in adults.^[3]

In most European countries, asthma-related hospitalizations recently declined, with an over two-fold reduction in some countries.^[4] While in Sudan, asthma is the fifth-highest cause of hospitalizations after pneumonia, malaria, diarrheal diseases, and diabetes.^[5] In addition, general hospitals have witnessed a dramatic increase in the number of emergency room (ER) visits by asthma patients in previous years.^[6]

Asthma morbidity is high in low-and middle-income countries (LMICs) since most patients have poor or limited access to healthcare and essential medicines.^[7] Most of the asthma patients seen in general practice have uncontrolled symptoms and poor knowledge and skills in asthma management, medication use, and inhaler technique.^[8] Poor asthma control is related to increased morbidity, healthcare utilization, healthcare costs, and mortality. Poor awareness and knowledge about asthma guidelines, suboptimal infrastructure, and diagnostic facilities^[9] as well as non-availability and high cost of asthma medications are among the health system factors that are associated with poor asthma control in LMICs.^[10] Patient-related factors such as sociodemographics, asthma education, active and passive smoking,^[11,12] adherence to medications and follow-up visits, and personal beliefs regarding asthma may influence asthma control.

In Sudan, despite the local adaptation of international guidelines and piloting asthma standard case management (SCM) proposed by the International Union against Tuberculosis and Lung Diseases (The UNION) which substantially reduced symptoms severity, ER visits, and hospitalizations,^[6] a recent study reported that the majority of asthma patients (58%) seen at referred clinics in Khartoum were not receiving medications as recommended by the international asthma guidelines.^[13]

Asthma control data from LMICs are scarce, and it is difficult to generalize data obtained in other parts of the world to specific ethnic and social contexts. Nevertheless, there is reasonable information on the level of asthma control from several countries in the Middle East and North Africa (MENA), but data from Sudan are lacking and the factors associated with asthma control are not well studied.

We conducted a study to determine the level of asthma control among patients attending tertiary hospitals in Khartoum and to identify the factors which may influence asthma control.

MATERIALS AND METHODS

RESULTS

Participants

Of 394 potential asthma patients approached at the outpatient’s clinics of the three hospitals, only 374 (94.92%) gave consent and completed the questionnaires. Seven participants were excluded from the study because their asthma diagnosis was not previously confirmed by a physician. Another five participants were excluded from the analysis because they had incomplete data [Figure 1].

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Figure 1:

Flow chart of the study sample. Based on asthma control test (ACT), a score ≤19 indicated “uncontrolled” asthma and a score ≥20 indicated “controlled” asthma.

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DISCUSSION

In this study from the MENA region, we found a very high prevalence of uncontrolled asthma (84.5%) among Sudanese adults attending three tertiary hospitals in Khartoum. We also found that the health facility, longer time to reach facility, steroids tablets use, non-adherence to follow-up visits, not having family history of asthma, and lack of training on inhaler technique were significantly associated with uncontrolled asthma.

Globally, several studies have also documented suboptimal asthma control. In population studies in five European countries, the prevalence of uncontrolled asthma was 53.5%.^[16] In the United States, 58% of asthma patients have uncontrolled asthma.^[17] In Latin America^[18] and Asia-Pacific^[19] and Nigeria,^[20] Asthma Insights and Management surveys reported 93%, 92.4%, and 93.8% of partly-controlled or uncontrolled asthma in these regions. In the MENA,^[21] uncontrolled asthma prevalence ranged from 57.4% to 85.2%, with an overall prevalence of 70.6% in 11 countries. In other African countries, including Cameroon, DR Congo, the Maghreb countries, and Ethiopia, studies have reported uncontrolled asthma prevalence of 42%, 56%, 71.3%, and 85.2%, respectively.^[22-25]

This high prevalence of uncontrolled asthma in our study may be related to the location of the study in tertiary care hospitals where patients with more severe diseases are likely to attend. This high level of uncontrolled asthma may be linked to the underuse of the recommended prophylactic medications since only (24.9%) of the patients used them in this study.

To achieve good outcomes in asthma control, the GINA^[26] and the UNION,^[7] recommend improving the quality of services provided to asthma patients through implementation of asthma guidelines, use of diagnostic tools such as peak-flow-meter and spirometer, provision of affordable quality-assured medications, and regular training of health providers.

We found that the health facility and its available resources for asthma are associated with uncontrolled asthma. Patients attending Ibrahim Malik hospital were almost 3 times more likely to have uncontrolled asthma compared to those attending Khartoum North hospital (OR = 2.96 [1.27–6.86]). Although both hospitals are tertiary, however, this could be explained by that the latter has a specialized asthma emergency room. In Nigeria, as of many LMICs, health-service factors such as poor awareness and knowledge among physicians regarding asthma guidelines, suboptimal infrastructure and diagnostic facilities, and non-availability and high cost of asthma medications were associated with poor asthma control.^[10,27] In fact, we found that the use of diagnostic tools for asthma diagnosis and management was very low since only 15.7% of patients had undergone peak flow meter measurement and only 12.4% were diagnosed for asthma using spirometry. Lung function assessment is recommended in asthma care and underuse of these tools has been associated with undertreatment of asthma and poor asthma control.^[28]

Longer time to reach health facility was associated with asthma control in this study. This is likely to lead to infrequent follow-up care for asthma as patients are likely to attend only when they have severe symptoms.^[20] Previous studies have also reported that underuse and access to healthcare are associated with poorer asthma control.^[29]

Family history of asthma is a known risk factor for asthma;^[30] however, its association with asthma control is not known; some reported that family history of asthma is not a key factor in asthma control once the guidelines are followed.^[31] We found that a family history of asthma is significantly associated with uncontrolled asthma. This might be due to those who had a family history of asthma may have better asthma control knowledge.

In this study, uncontrolled asthma was associated with oral steroids use without prescription (OR = 9.01 [1.01–79.88]). This is similar to findings from another study where uncontrolled asthma was significantly associated with oral steroid dispensing (OR = 2.6 [1.9–3.5]) even after adjusting for demographic characteristics.^[32] The use of oral steroids without prescription might indicate that these patients were not on regular controller medication or with a more severe form of disease and therefore they were experiencing asthma control difficulties.

We also found in this study, non-adherence to follow-up is associated with uncontrolled asthma. Similarly, in the Maghreb, asthma control was associated with the frequency of physician consultation, with subjects who consulted less frequently for asthma being better controlled. This reflected the fact that the majority of study subjects only consulted their physician in case of exacerbations, with only one-third of them reporting programmed follow-up consultations.^[24]

Inhaler technique was associated with asthma control in this study. This finding is consistent with reports from several studies. A study conducted in Saudi Arabia revealed that improper use of asthma inhaler was associated with uncontrolled asthma.^[11] Similarly, reports from Ethiopia^[25] and Nigeria^[33] showed that incorrect inhaler technique was associated with uncontrolled asthma with an OR of 2.5 (1.26–4.98) and 18.9 (2.3–155.6), respectively. Improper use of inhalers might possibly lead to a reduction in drug delivery and drug effectiveness and consequently contributes to uncontrolled asthma found among these patients.

One of the strengths of our study is that this is the first report of the level of asthma control and its associated factors from Sudan, adding data to the wider MENA region. The cross-sectional nature of the study brings with it its limitation, including that the associations do not imply causality. As patients were selected on the basis of self-report, this may have resulted in selection bias. Moreover, patients were recruited from outpatient’s clinics and this may have increased the prevalence of uncontrolled asthma reported in this study. Recall bias may have also influenced the responses provided by the patients with uncontrolled asthma compared to those with controlled asthma to some events such as their adherence to follow-up visits and steroids tablets use. Moreover, the number of participants with controlled asthma was small and made some associations difficult to establish or to interpret. Although we have recruited patients from all over Khartoum state, exclusion of the other healthcare facilities, including the private and military hospitals, would limit the generalizability of the results. Nevertheless, the study has the merit of reporting the level of asthma control and its associated factors among Sudanese patients attending tertiary care hospitals. These findings, coupled with further research including different care levels, will enable tailoring targeted management interventions.

CONCLUSION

The level of asthma control reported in this study is very low despite the possibility of applying proven, cost-effective interventions in LMICs, particularly asthma SCM.^[6,34,35] Our study adds important new data on the factors associated with asthma control among Sudanese patients attending these tertiary care hospitals. Our finding highlights the need for an integrated approach to asthma management where patient’s knowledge about asthma control, including the need for adherence to medication, adherence to follow-up visits, and inhaler technique training, is prioritized.