Assessment of levels of asthma control among adult patients with asthma at Chitungwiza Central Hospital, Zimbabwe

Asthma is defined as a heterogeneous disease, usually characterized by chronic airway inflammation and reversible airway obstruction [1]. It affects an estimated 300 million people of all ages worldwide [1]. It is thus important to manage this reversible airways obstruction as it forms the cornerstone to quality asthma management [1, 2]. Asthma control is the extent to which numerous clinical presentations of asthma are reduced or removed by asthma treatment [3]. The control of asthma ensures that patients with asthma live their daily lives as healthy people do [3].

In order to achieve good control of asthma, the treatment should result in day and night symptoms less than 4 times per week, improve performance of daily activities, reduce asthma attacks, and that reliever treatment be less than four times per week [4]. In addition, good quality management of asthma requires that the patient adheres to the prescribed treatment. The treatment should include the use of controllers AND quick RELIEVERS [5, 6]. Glucocorticosteroids, β2-agonists and anti-leukotriene are the medical treatments most commonly recommended for the asthma patients. The patients need to have a good knowledge of the asthma disease in order to be able to follow the treatment regimens and to use different inhalers; and to avoid factors that can cause or trigger complications. Often lifestyle changes such as the need for daily medication, stopping habits of smoking, identifying and avoiding triggers as well as regular physical exercise, are necessary to achieve asthma control [7].

According to Nieuwenhof et al. [8], a high number of adult asthma patients were not adequately controlled despite effective asthma treatments being available. Further, studies have indicated that the major reason for poor asthma control is patients’ failure to adhere to their treatment [9]. Assessing asthma control level could give an insight into the level to which quality of care is rendered to the asthma patients. One assessment tool that has been widely used to ascertain the levels of asthma control is the Asthma Control Questionnaire (ACQ)© which was developed to assess the effectiveness in quality management of asthma [10]. The ACQ has undergone a rigorous validation process [10] and has been standardized and validated in a number of settings [11] which include South Africa and European countries studies [12‐14] have shown that the ACQ questionnaire is valid for measuring asthma control and provide a strong assessment tool that can be used in clinical practice and research. However, although there have been studies assessing levels of asthma control [3, 14, 15] elsewhere, there have been no documented studies on levels of asthma control within the Zimbabwean population. The aim of this study therefore, was to assess level of asthma control in a Zimbabwean adult asthma population attending Chitungwiza Central Hospital.

A total of 400 participants 261 (65.3% females) with asthma participated in the study. The majority 245 (61.2%) were married, 97 (24.3%) were single while 36 (9%) and 22 (5.5%) were widowed and divorced respectively. There were significant differences between males and females with controlled asthma. The results of the study further showed a significant difference between males and females with uncontrolled asthma (p ≤ 0.001). Those participants who attained secondary level of education were 159 (39.7%). Those who had a primary, college and university level of education were 60 (15%), 127 (31.8%) and 54 (13.5%) respectively. There are significant differences between participants who attended primary school and those that had secondary and college school education regardless of asthma control status (p = 0.001). With regards religion, 163 (40.7%) reported to be Pentecostal, 100 (25%) were Apostolic, and 79 (19.8%) were Protestants. Slightly above half 201 (50.3%) reported to be employed. The majority 272 (68%) resided in urban areas, and the least 26 (6.5%) were from surrounding farms.

Among those 152 (38%) who had controlled asthma, the Pentecostals 68 (44.7%) were the most, followed by the Apostolic. However, for uncontrolled asthma, 95 (38.3%) and 68 (27.4%) were the Pentecostal and protestants respectively. Among the Apostolic, more had significantly controlled asthma (p = 0.001). However, the protestants had a significantly uncontrolled asthma (p < 0.001).

On analysis, there were more study participants 248 (62%) who had uncontrolled asthma. The median age for the participants was 33 years (IQR: 25.5–41 years) in those with controlled asthma and was 35 years (IQR: 27–44 years) in those with uncontrolled asthma. Of the 152 participants who were classified to have controlled asthma, more than half 103 (67.8%) were married. Of the 248 participants classified to have uncontrolled asthma, 30 (12.1%) were widowed.

From a total of 152 participants who had controlled asthma, 51 (33.6%) apostolic sect members reported controlled asthma. On the contrary, from the 248 participants who reported to be protestants, 68 (27.4%) had uncontrolled asthma. The distribution of apostolic participants was different to Pentecostal and protestants participants for all groups (p < 0.001). A Chi-square test was performed to identify an association (p-value < 0.05) between participants’ demographic characteristics and asthma control status. The distribution of participants by area of residence was consistent regardless of asthma control status (p < 0.001). Participants from urban areas were different from peri-urban, rural and those from farms in both control groups (controlled and uncontrolled). The distribution showed significant differences between employed and unemployed participants in both controlled asthma and uncontrolled asthma participants (see Table 1).

Table 2 compares the ACQ asthma mean scores for the 7 item questions. Using the ACQ asthma control mean scores, 152 (38%) participants had a controlled asthma (FEV1%: ≥ 80). Those with a mild uncontrolled asthma (FEV1%: 60–79) contributed to 72 (18.8%), while 50 (12.5%) were moderately uncontrolled (FEV1%: 51–59). The remaining 123 (30.8%) had very uncontrolled asthma (FEV1%: ≤ 50). All the 7 ACQ items indicated significant differences in asthma mean scores (p < 0.001). Bonferroni analysis to distinguish between paired groups using ANOVA showed that all the identified questions (1–6) were significantly different. The predicted FEV1% for the mean scores for the controlled asthma group against moderately uncontrolled and very uncontrolled asthma groups were significantly different (p ≤ 0.001). The predicted FEV1% for the mean scores for the mildly uncontrolled asthma group against moderately uncontrolled and very uncontrolled asthma groups were significantly different (p = 0.003).

This study aimed to measure the level of asthma control in a Zimbabwean adult asthma population attending the research study clinic at a central hospital. Results indicated that most patients had uncontrolled asthma. Our results resonate those reported in South Africa where 47.2% of patients were controlled [27]. In addition, studies from high-income countries have also highlighted this trend with a multi-country study conducted in five European countries indicating that more than half (56.6%) of treated asthmatics were not well controlled which is in tandem with our findings [28].

Such results are important for a number of reasons. For instance, the high levels of uncontrolled asthma present opportunities for healthcare providers to institute interventions, which will improve asthma treatment. Second, there will be need for more studies to explore patient related and health service related factors contributing to uncontrolled asthma in resource-limited settings such as ours.

Our study has shown that a better control of asthma was amongst the Pentecostal sect members. This could be as a result of the fact that members of the Pentecostal religion engage in medical pluralism which allows them to take medication and faith healing. Further, our study has shown that members of apostolic sect members had a better control of asthma compared to Protestants despite the known fact that apostolics do not normally seek care at health facilities. This is especially interesting to note that a better control of asthma was amongst the apostolic sect participants compared to the Protestants. Within our setting, the apostolic do not provide shelter for their congregants and spend most of their time under trees and in open spaces, which are dusty, and wind-blown whilst the Protestants provide shelter for their congregants and emphasize on clean environments. This finding is further supported by the hygiene hypothesis [15]. Further the result in this study is surprising given that the Protestants whose level of utilization of hospital services is better than that of the apostolic sects in Zimbabwe. Therefore there could be need to study what the apostolic are doing which lead to better asthma control.

Our results showed that those employed had controlled asthma while those that were unemployed had uncontrolled asthma. Such results may be explained in part, by the fact that patients who are likely to be employed may be better informed and have a better quality of life which may lead them to be more compliant to treatment regiments and recommendations from healthcare personnel. Additionally employed patients may be in a better position to afford healthcare services in a setting such as Zimbabwe where health care costs are expensive for those without a steady income [29]. Previous studies have shown that employment status is associated with controlled/uncontrolled asthma [30, 31].

Results from the current study indicated that being married was associated with having well-controlled asthma which might be due to the fact that married couples could be having more social support. However, our results further elaborated that those that were widowed, separated or divorced were likely to be associated with uncontrolled asthma. This may be due to the fact that widowhood and to some extent being divorced, erodes social and financial support. Similar to our findings, researchers from India reported that being widowed was associated with more adverse health outcomes for patients with chronic conditions [32]. Furthermore, our results concur with those of Zhang et al. [33] that showed that married individuals were likely to have better survival outcomes because their spouses cared for them and encouraged them to have a positive outlook. There is thus need to strengthen health promotion interventions targeting groups such as the widowed in an effort to improve the quality of life of asthma patients.

Another key determinant of poor asthma control that emerged from the results of this study pertain to the participants’ area of residence. For instance residing in urban areas appeared to be protective against uncontrolled asthma with those participants from farming communities having more uncontrolled asthma levels. Reasons for such discrepancies are however not clear, and the authors hypothesize that it could be due to differences in socio-economic statuses with urban dwellers being more affluent and hence could be having more contact with healthcare providers in addition to proximity of the hospitals and other health centres within their neighbourhoods. Our study findings concurred with the findings of a study by Braido, et al. [30] and Ghanname et al. [34] who showed that those staying in urban setting were more likely to be asthma controlled and those staying in the rural/villages being asthma uncontrolled. However, care must be taken in interpreting this result as our study was urban based and as such rural patients could have been misrepresented as they were fewer than their urban counterparts. Future studies could potentially compare patients attending rural health centres and urban ones.

In this study asthma control is significantly different within asthma control groups. The results may reflect the need to step up asthma treatment according to level of asthma control if we are to achieve best asthma control.

Although good asthma control can be achieved for most patients, the reality in clinical practice based on this study, it seems to suggest that asthma remains poorly controlled. Our study concluded that the majority of asthma patients who were being treated at Chitungwiza Central Hospital in Zimbabwe had uncontrolled asthma. This indicates the need to improve quality of care to these patients if control of asthma is to be achieved. There is also need to carry out a study that does not follow a community engagement approach, as this might have lead to most of those with uncontrolled asthma reporting to the research study clinic. The use of ACQ may provide the health care providers with a good and efficient starting point to actively and timely detect patients with uncontrolled asthma symptoms in clinical practice.