Abstract
Objective:
Asthma is a major public health problem worldwide. Despite various attempts, it is still uncontrolled in most parts of the world. Moreover, it is contributing to the national and global burden of non-communicable diseases. Studying factors associated with uncontrolled asthma in different parts of Ethiopia is crucial to control the disease and improving the quality of life of asthmatic patients. Thus, this study aimed to determine the factors associated with uncontrolled asthma among adult asthmatic patients in Eastern Ethiopia.
Methods:
Facility-based cross-sectional study was employed from 1st October 2020 to 30th January 2021. A total of 416 adult asthmatic patients participated in the study from six hospitals follow-up clinics. Asthma control test was used to assess the participants level of asthma control and a score of ⩽19 were regarded to have uncontrolled asthma. Data were analyzed using SPSS version 24. Bivariable and multivariable analyses were carried out to identify factors associated with uncontrolled asthma and variables with a p value of less than 0.05 were considered statistically significant.
Result:
The prevalence of uncontrolled asthma was 66.1 % (95% confidence interval: 61.5–70.4). Not attending scheduled medical follow-up (adjusted odds ratio: 2.54; 95% confidence interval: 1.28–4.99), poor knowledge about asthma (adjusted odds ratio = 4.59; 95% confidence interval: 2.01–10.51), negative attitude toward asthma (adjusted odds ratio = 3.72; 95% confidence interval: 1.83–7.59), and poor adherence to medications (adjusted odds ratio = 2.53; 95% confidence interval: 1.25–5.13) were significantly associated with uncontrolled asthma.
Conclusion:
In this study, the prevalence of uncontrolled asthma was considerably high. Not attending scheduled medical follow-up, poor knowledge about asthma, negative attitude toward asthma, and poor adherence to anti-asthma medications were associated with uncontrolled asthma. Therefore, it is crucial to focus on increasing the patients’ level of awareness about asthma control, improving medication adherence, and avoiding triggering factors.
Introduction
The global morbidity and mortality from non-communicable diseases such as cardiovascular diseases, diabetes, cancer, and chronic respiratory disorders are on the rise. Chronic respiratory diseases were the third leading cause of death worldwide resulting in 7% of deaths.1,2
Asthma is a respiratory non-communicable inflammatory disease affecting a large number of people irrespective of age, sex, or socioeconomic status. 3 It affects both developed and developing countries and poses a major problem irrespective of their economic development.3,4 In 2019, more than 461,000 people died from asthma worldwide, with an estimated 262 million individuals suffering from the disease. 5 Poor and middle-income nations account for more than 80% of asthma mortality. 4 Asthma prevalence has increased in Africa during the last two decades, with an estimated 119.3 million people affected.6,7 According to the data of a cross-sectional world health survey conducted in 2012, the prevalence of clinical asthma in Ethiopia was 2%. 8
Uncontrolled asthma harms the individual, family, and national levels. It causes various serious issues, adding to the national and global burden of non-communicable illnesses. It also results in mortality and studies showed that oral corticosteroid use is associated with an increased risk of mortality among asthmatic patients.9,10 In addition, it reduces and limits the physical activity, mood, and social life of asthmatic patients, lowering their quality of life and productivity.8,11
Asthma cannot be cured, but if effective asthma care and management are employed, most individuals with asthma can control it since monitoring the level of asthma control is an important component of effective asthma care and management.12,13 Despite efforts to incorporate international asthma management guidelines and the presence of an internationally standardized tool to measure the level of asthma control, the prevalence of uncontrolled asthma in Ethiopia remains high, ranging from 53.3% to 75.8%. 14 In the studies conducted in Ethiopia, factors including poor knowledge about asthma, negative attitude toward asthma, non-adherence to inhaled corticosteroids, longer duration of asthma, asthma exacerbation in the last 12 months, low monthly income, presence of comorbidity, and use of short acting beta2 agonist alone as anti-asthmatic medication were significantly associated with uncontrolled asthma.15–18
Approaches to improve symptom control have the potential to significantly reduce both the humanistic and economic burdens of asthma. However, just a few researches have been conducted to determine the substantial percentage of uncontrolled asthma and predicting factors in Ethiopia. Those studies were done in a single hospital and assessed a few variables that might be associated with uncontrolled asthma, but this is a multicenter study conducted in different types of hospitals including different independent variables and different types of patients which in turn helps to determine the true burden of the problem in the country. Thus, this study is intended to investigate the prevalence and determinants of uncontrolled asthma in Eastern Ethiopia to tailor national strategies and interventions.
Methods
Study setting and study design
Facility-based cross-sectional study was conducted from 1st October 2020 to 30th January 2021, in six hospitals that are found in Harar and Dire Dawa, Eastern Ethiopia. Hiwot Fana Comprehensive Specialized Hospital, Jugal General Hospital, and Federal Police Harar General Hospital are located in Harar whereas Dilchora Referral Hospital, Sabian General Hospital, and East Command Level Three Referral Hospital are found in Dire Dawa.
Ethics approval
The study was conducted following the Declaration of Helsinki Ethical principle for medical research involving human subjects. The ethical approval was obtained from the Institutional Health Research Ethical Review Committee (IHRERC) of the College of Health and Medical Science of Haramaya University with the reference number of (IHRERC/014/2020). An official letter of cooperation was written and submitted to the respective health bureaus, and hospitals. Informed written voluntary consent was obtained from the heads of the hospitals and all the study participants. Participants’ confidentiality was maintained throughout the process.
Population and sample
The study included asthmatic patients over the age of 18 years who had been taking anti-asthmatic medications for at least 6 months, where the diagnosis was based on medical history, physical examination, and spirometer results. Asthmatic patients who were mentally unstable or critically ill and patients with physician-diagnosed chronic obstructive pulmonary disease, active respiratory infections, congestive heart failure, and pulmonary hypertension were excluded from the study. The sample size was calculated by using single population proportion formula considering a 95% confidence interval (CI), a 5% margin of error, and a proportion of 53.3%. 17 After adding a 10% non-response rate, the final sample size was 420. Prior 6 months of patient enrollment records from the respective hospitals’ follow-up registration books were used to proportionally allocate the sample size, and then a consecutive sampling method was applied to recruit study participants.
Data collection instruments and procedure
Data were collected by face-to-face interviews using a structured and pretested questionnaire. Six trained nurses participated in the data collection process. The questionnaire was first prepared in English, then it was translated to Amharic, Afaan Oromo, and Af Somali languages by language experts and it was back-translated to English to check for consistency. The questionnaire included socio-demographic characteristics and patients’ treatment history and disease-related factors. To assess the level of asthma control, the Asthma Control Test (ACT) tool which includes five questions was used. Participants in the study with scores greater than 19 were deemed to have controlled asthma, while those with scores less than or equal to 19 were regarded to have uncontrolled asthma. 19 The Medication Adherence Reporting scale (MARs) which includes 10 questions was used to assess participants’ level of medication adherence. To minimize the social desirability bias, the questions were framed as negative statements. It was measured based on 5 points Likert-type scale ranging from always to never. Accordingly, participants who scored a mean value of 4.5 and more were considered to have good adherence.20,21 The study participants’ knowledge about asthma was assessed by 20 questions. Accordingly, participants who scored greater than or equal to 13 were considered to have good knowledge, 9–12 average knowledge, and ⩽8 poor knowledge.22,23 Five questions on a 5-point Likert-type scale were used to examine patients’ attitudes toward asthma. Participants with scores greater than or equal to 15 were classified as having a positive attitude, while those with scores less than 15 were classified as having a negative attitude.22,23 Lung function test was measured and Forced Expiratory Volume in 1 second (FEV1) was recorded by portable digital Diagnostic Easy One Plus model 2001 SN spirometer. Body mass index (BMI) was calculated and those respondents with values <25 kg/m2 were categorized as underweight or normal, respondents with BMI between 25 and <30 kg/m2 were categorized as overweight, and the remaining, whose BMI was ⩾30 kg/m2 were categorized as obese. 24
Data quality control
Pretest was conducted among 5% (21) of the sample size at Haramaya Hospital, in Haramaya district. Data collectors and supervisors were trained on the research objectives, data collection tools, procedures, and interview techniques for one day. An introductory orientation was given to the study participants by data collectors about the purposes of the study. Informed written voluntary consent was taken from all selected participants before the data collection. Data were first checked for completeness and consistency and then double data entry was done and cross-validated.
Statistical analysis
The data were entered into Epi-data version 3.1.0 and exported to SPSS version 24 for analysis. Descriptive statistics including frequencies, percentages, median, range, and interquartile range (IQR) were computed to describe the variables. Bivariable logistic regression analysis was done to determine the association between each independent variable and uncontrolled asthma. All the variables with a p value less than 0.25 in the bivariable analysis and clinically important variables were entered to the final multivariable logistic regression. To identify factors associated with uncontrolled asthma, multivariable analysis was carried out. To measure the strength of association, crude odds ratio (COR) and adjusted odds ratio (AOR) along with 95% CI were estimated. The Hosmer–Lemeshow test was used to determine the model’s fitness, and a p value greater than 0.05 was considered fit. Multico-linearity test was carried out to see the correlation between independent variables using a variance inflation factor (>10). To declare the presence of statistical significance, a p value of <0.05 was taken.
Result
Socio-demographic characteristics and patient-related factors
The study included 416 participants. The median (25th–75th percentile) age of participants was 41 years (30–50) with a range of 18–79. Of the total participants, 215 (51.7%) were females, 247 (59.4%) were married, the BMI for 262 (63%) of the participants was normal or underweight, the majority of them 91.6% were urban residents and 174 (41.8%) had monthly income between 1201 and 2499birr (22.94–47.76$). Of the total participants, 243 (58.4%) did not attend their regular medical follow-up as scheduled. This study also showed that 357 (85.8%) participants had never smoked, 243 (58.4%) of them chew khat, 186 (44.7%) had poor knowledge about asthma, and 217 (52.2%) had a positive attitude toward asthma (Table 1).
Socio-demographic characteristics and patient-related factors of adult asthmatic patients on follow-up at governmental hospitals, eastern Ethiopia.
BMI: body mass index; ETB: Ethiopian Birr.
Other: no occupation, student.
Prevalence of uncontrolled asthma
In this study, the prevalence of uncontrolled asthma was 275 (66.1%; 95% confidence interval: 61.5–70.4), while the prevalence of controlled asthma was 141(33.9 %).
Disease-related factors
Two hundred fifty-seven (61.8%) of the study participants use medications regularly to control asthma, and the remaining 159 (38.2%) use them only to relieve signs and symptoms. Most of the study participants 355 (85.3%) used Short Acting Beta2 Agonist (SABA) inhalers. Among those who used anti-asthma medications, 147 (35.3%) had poor adherence to medications. The median (25th–75th percentile) duration of asthma was 6 years (3–12.75) with a range of 1–41 years. Around half of the study participants, 211(50.7%) had asthma exacerbation in the past 12 months, 164 (39.4%) had a comorbid illness, and only 47 (11.3%) were admitted to the hospital within the past 12 months. The reason for hospital admission for 17 (36.2%) out of the 47 admitted patients was asthma, and 133 (32%) of the study participants had a family history of asthma. Forced Expiratory Volume in 1 s was less than 80% in 245 (78.3%) of the participants. Three hundred twelve (75%) mentioned seasonal variation as their major asthma triggering factor (Table 2).
Disease-related factors for adult asthmatic patients on follow-up at governmental hospitals, eastern Ethiopia.
SABA: short acting beta2 Agonist; ICS: inhaled corticosteroid; OCS: oral corticosteroid; LABA: long acting beta2 agonist; FEV1: forced expiratory volume in 1 s.
Others: chronic kidney disease, breast cancer, chronic liver disease, and thyroid disease.
Other; for child birth, diabetic ketoacidosis, pneumonia, tuberculosis, appendicitis, head injury, peptic ulcer disease, and anemia.
Others: strong odor, aspirin, and detergent.
Factors associated with uncontrolled asthma
Bivariable logistic regression was used to assess an association between different factors and the occurrence of uncontrolled asthma. Those variables which showed an association at p value < 0.25 and clinically important variables were entered into the multivariable logistic regression model. In the multivariable analysis, participants who did not attend their scheduled regular follow-up had 2.5 times higher odds to have uncontrolled asthma than those who attended their regular follow-up. (AOR: 2.527; 95% CI: 1.281–4.986). Asthmatic patients who had poor knowledge about asthma had 4.5 times higher odds to have uncontrolled asthma than those who had good knowledge (AOR: 4.593; 95% CI: 2.007–10.514). Patients who had a negative attitude toward asthma had 3.7 times higher odds to have uncontrolled asthma than those who had a positive attitude (AOR = 3.724; 95% CI: 1.825–7.597). Participants who had poor medication adherence had 2.5 times higher odds to have uncontrolled asthma than those who had good medication adherence (AOR = 2.533; 95% CI: 1.251–5.128; Table 3).
Bivariate and multivariate analysis for factors associated with uncontrolled asthma among adult asthmatic patients on follow-up at governmental hospitals, eastern Ethiopia.
COR: crude odds ratio; CI: confidence interval; AOR: adjusted odds ratio; BMI: body mass index; SABA: short acting beta2 agonist; OCS: oral corticosteroid; ETB: Ethiopian birr.
Statistically significant at p < 0.05.
Discussion
A total of 275 (66.1%) of the respondents in this study had uncontrolled asthma. Not attending regular medical follow-ups, poor knowledge about asthma, negative attitude toward asthma, and poor adherence to medications were significantly associated with uncontrolled asthma.
This study revealed that the prevalence of uncontrolled asthma was 66.1%. According to studies from health facilities in the Middle East and Northern Africa, the United States, and China, 41.5%, 50%, and 31.6% of patients, respectively, had uncontrolled asthma.16,25–28 Asthma control among patients living in developed nations could be better as there are superior health infrastructures, quality care provision, and a sufficient quantity of health care personnel. Comparable results (70.1%) were found in a local study conducted in Gondar, Ethiopia. 17 In contrast, studies from other parts of the country reported lower percentage of uncontrolled asthma. For example, a study from Addis Ababa, Ethiopia discovered a 53.3% prevalence of uncontrolled asthma, whereas a study from Jimma discovered 50.4% prevalence.16,28 This disparity may be explained by differences in study regions and the number of study settings. Furthermore, the higher values in this study may be related to the larger sample size used, as well as the inclusion of more health facilities. Nonetheless, this study showed the need for stringent action to be taken in response to the problem.
It was found that not attending scheduled regular medical follow-ups was significantly associated with uncontrolled asthma. Participants who did not attend their scheduled regular follow-up had 2.5 times higher odds to have uncontrolled asthma than those who attended their regular follow-up. This is in line with the one conducted in Jimma University Specialized Hospital, Ethiopia. 28 The significant association might be due to that attending and following scheduled medical follow-up helps the patients to control their asthma with the help of healthcare professionals.
In this study, participants who had poor knowledge about asthma had 4.5 times higher odds to have uncontrolled asthma than those who had good knowledge about asthma. This finding is similar to the one conducted in Jimma University medical center, Ethiopia. 23 This significant association might be due to the fact that poor knowledge about asthma affects the patients’ practice to control their asthma. Having inadequate knowledge about asthma triggering factors, signs and symptoms, management of acute exacerbation of asthma, and when and how to take prescribed medication might lead to uncontrolled asthma.
Participants who had a negative attitude toward asthma had 3.7 times higher odds to have uncontrolled asthma than those who had a positive attitude. This study is in line with the study done at Jimma University medical center, Ethiopia. 23 This might be because having a negative attitude toward the sign and symptoms, management, triggering factors, and other aspects of asthma might lead asthmatic patients to practice unacceptable management measures to control asthma.
In this study, participants who had poor medication adherence had 2.5 times higher odds to have uncontrolled asthma than those who had good medication adherence. This finding is in line with the studies done in Jimma university medical center, Ethiopia and China.23,29 But it is different from the one conducted in the Middle East and North Africa, where asthmatic patients who had poor medication adherence were 0.5 times less likely to have poorly controlled asthma than those who had good medication adherence. 26 The discrepancy might be due to the difference in sample size, which was around 16 times higher than this study. In addition to the above reason the significant association between poor knowledge and negative attitude with uncontrolled asthma in this study might lead to poor medication adherence.
Generally, this study will be useful for policymakers to plan and incorporate health education programs to the level of specific knowledge regarding asthma and establish a care delivery system that allows training concerning level of asthma control. It is also used for the patients since this study helps the health care professionals to enhance knowledge of asthmatic patients through regular health education about different aspects of asthma.
Strength and limitation
This study was conducted in six hospitals including general and referral hospitals which helped us to recruit different types of patients with different characteristics. Using the standardized and internationally validated ACT questionnaire tool was also a strength. Despite being a multicenter study, this study’s results are not without limitations. The use of cross-sectional study design cannot show cause and effect relationships. Only FEV1 was recorded from the spirometer thus we were not able to evaluate the effect of airflow obstruction in the multivariable model. In addition, some of the data were collected by recalling things from the past so; it might have caused a recall bias.
Conclusion
There was a high prevalence of uncontrolled asthma in this study. Factors including not attending scheduled regular medical follow-ups, poor knowledge about asthma, negative attitude toward asthma, and poor adherence to medications were associated with uncontrolled asthma. Thus, it is important to improve the level of asthma control through different methods by incorporating professionals, administrators, policymakers, and researchers.
Supplemental Material
sj-docx-1-smo-10.1177_20503121221132165 – Supplemental material for Factors associated with uncontrolled asthma among adult asthmatic patients in eastern Ethiopia: A multicenter study
Supplemental material, sj-docx-1-smo-10.1177_20503121221132165 for Factors associated with uncontrolled asthma among adult asthmatic patients in eastern Ethiopia: A multicenter study by Helina Heluf, Nega Assefa, Yadeta Dessie, Abel Tibebu Goshu, Gelana Fekadu, Lemesa Abdisa and Dawit Tamiru in SAGE Open Medicine
Footnotes
Acknowledgements
The authors would like to thank Haramaya University, College of Health and Medical Sciences for the technical support provided. They thank the staffs and administrators of the respective hospitals and the patients who were willing to participate in the study. They also would like to acknowledge Research Square for publishing our manuscripts’ preprint.
Authors contribution
All the authors made a significant contribution in the conception, study design, execution, acquisition of data, analysis and interpretation, all of them took part in drafting, substantially and critically reviewing the article; have agreed on the journal to which the article is going to be submitted; agreed on all versions of the article before submission,; and agreed to be accountable for all aspects of the article.
Availability of data and materials
All the data are available from the corresponding author upon reasonable request.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethics approval
The ethical approval for the study was obtained from the Institutional Health Research Ethical Review Committee (IHRERC) of the College of Health and Medical Science of Haramaya University on February 17 (Ref. No. IHRERC/014/2020).
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by Haramaya University. However, the funding institution has no role in the publication consent or approval.
Informed consent
Official letters of cooperation were written and submitted to the respective health bureaus, and hospitals. Informed written voluntary consent was obtained from all the study participants and their confidentiality was maintained throughout the process.
Supplemental material
Supplemental material for this article is available online.
References
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