Introduction
Asthma is a growing public health burden in low- and middle-income countries (LMICs); worldwide, approximately 1000 people die every day, with the majority of deaths occurring in LMICs [
1]. Asthma is the most common chronic disease among children and is a major cause of morbidity [
2]. Limited data suggest that asthma prevalence is increasing among children in African countries, with those affected suffering more severe symptoms than children from high-income settings [
3]. There are no published asthma prevalence data for Malawi. Children with acute asthma attacks frequently attend for emergency care at the country’s largest tertiary hospital, Queen Elizabeth Central Hospital (QECH): severe cases require hospital admission with considerable associated costs for the child, family and health system.
Achieving good symptom control is a primary goal in asthma management and adherence to treatment plays a key role [
4]. Adherence is enhanced if the family has a positive view of asthma, understand the need for regular inhalers and trust the medication [
5]. During childhood, parents or carers are primarily responsible for medication administration, identification and avoidance of triggers and obtaining prescriptions [
6]. However, older children can take an increasingly active role is self-management of their asthma [
7]. Successful asthma care then requires that both children and parents receive adequate information on asthma, triggers, medication and self-management of symptoms.
Asthma education is central to the Global Initiative for Asthma (GINA) recommendations, which emphasize the importance of a strong partnership between patients and health care providers [
4]. Provision of asthma education to children and their families reduce the mean number of hospitalizations and emergency room visits in high income countries (HICs) [
8].
Asthma care in LMICs is often delivered in overburdened health care settings, and health care providers may have little time to spend on asthma education. Task-shifting, defined as “the transfer of tasks normally performed by a more to a less qualified cadre with a different level of education and training, or to a person specifically trained to perform a limited task only, without professional education”, has been suggested as an effective and affordable strategy to improve the management of non-communicable diseases in LMICs [
9]. However, there are limited data on task-shifting in asthma care in LMICs, and the use of non-clinical personnel has not been explored [
10]. Considering this, we designed an intervention to improve care at a tertiary hospital in Malawi, including individualised asthma education delivered by non-clinical staff [
11].
In this qualitative sub-study, the overarching research question was ‘is delivering asthma education using non-medical staff feasible and acceptable in our setting?’ To answer this question, we aimed to explore the experiences of the asthma educators, the patients and their carers participating in the asthma education sessions, in order to: (1) assess the acceptability of using non-clinical staff to deliver asthma education; (2) understand facilitators and barriers to asthma education; (3) assess the perceived value of the education sessions to children and their carers.
Methods
The asthma education intervention
This qualitative sub-study was part of a randomised-controlled trial (RCT), recruiting children aged 6–15 years with a doctor-diagnosis of asthma from the paediatric outpatient clinic at Queen Elizabeth Central Hospital (QECH), a tertiary government hospital in Blantyre, Malawi (Pan African Clinical Trials Registry reference PACTR201807211617031) [
11]. Participants and their carers attended an asthma education session, delivered by non-clinical staff (“asthma educators”) as part of the study intervention. The asthma education session followed a standardised approach, with educators completing a checklist to ensure consistency within and between study personnel. Asthma education was reinforced at subsequent study visits by the educators. As part of the study team, a senior research nurse provided the educators with daily clinical support and complicated cases were discussed with a consultant paediatrician (SR). The asthma educators were individuals with no clinical training but had completed at least 12 years of formal education (primary and secondary education) and attained the Malawi School Certificate of Education (MSCE). Prior to study initiation, the educators underwent a structured training programme, designed and delivered by a consultant paediatrician (SR), including clinic observations, tutorials and role play (see Additional file
1).
In total, 120 participants were recruited to the RCT between September 2018 and December 2019; the qualitative assessment of the asthma education intervention was conducted between August 2019 and March 2020.
Study site
QECH, a tertiary-level, government referral hospital is located in Blantyre, the second largest city in Malawi, in the Southern region. Outpatient asthma care at QECH is usually provided in a busy, under-staffed general paediatric clinic, with little time for assessing asthma control or providing asthma education. Primary health care in Malawi is offered at health centres within communities. Although some health centres within Blantyre city review asthma patients, inhaled medication is mostly unavailable and patients are referred to QECH.
Study design
The sub-study used qualitative research methods including focus group discussions (FGDs) with study participants and their carers and in-depth interviews with study staff (Table
1) [
12]. We incorporated a phenomenological approach to help us understand lived experiences and people’s perspective of the asthma education and their interpretation more inductively. We interviewed all the study staff who were involved with the intervention: four lay educators and the senior nurse who supervised them. The children and carers that attended the FGDs were purposively sampled and we continued to conduct the FGDs until saturation was reached. These aimed at gaining deeper insight into the facilitators and barriers to the educational aspect of the intervention.
Table 1
Qualitative study participants, attending focus group discussions and interviews
Focus Group Discussions (FGDs) |
Mothers and other female carers | 21 | 3 FGDs | Exploring the children’s and carers’ experience of the asthma education including barriers and facilitators to the intervention, their perceptions of the asthma educators as non-medical staff delivering the asthma education, their perceived value of the asthma education and recommendations for future interventions |
Fathers and other male carers | 7 | 1 FGD |
Children | 15 | 2 FGDs |
Total FGD participants | 43 | | |
In depth interviews |
Asthma educators | 4 | 4 interviews | Asthma educators’ experience of delivering the asthma education, their training and other mechanisms for support, perceived benefits to the children, facilitators and barriers to delivery and recommendations |
Research nurse | 1 | 1 interview | Exploring her experience in supervising the asthma educators and the barriers or facilitators to delivery, uptake of the asthma education and recommendations |
Total interview participants | 5 | | |
Data collection
FGDs and interviews were conducted in Chichewa by a research assistant (LN), a native Chichewa speaker, trained and certified in qualitative research methods, who was separate to the RCT study team. The discussions were led using semi-structured topic guides and recordings were transcribed verbatim and translated into English for further analysis.
Eligibility criteria
Participants were approached following completion of the RCT intervention. Children (aged ≥ 10 years) and their carers were purposively sampled to ensure that different key characteristics were represented: age, sex, and asthma severity. Only parents or carers who attended the asthma education sessions were included. Due to Malawian cultural norms, men often dominate discussions: male and female carers were therefore invited to attend separate FGDs to encourage free participation.
Individual interviews were conducted with each of the “asthma educators” and with the research nurse who had supervised the sessions. Interviews took place in a private location, with full confidentiality assured to encourage honest and open participation.
Data analysis
Data analysis was conducted iteratively alongside data collection, to allow exploration of emerging issues in later interviews and FGDs. A thematic approach was adopted, with all transcripts coded independently by three authors (LN, SR and FL) manually and later compared to enhance the rigour of the results. We also triangulated our data by considering perspectives and experiences from the carers, children and the educators to further enhance the validity and rigour of our findings. A coding framework was developed by the authors (LN, SR and FL) which was used to code all the transcripts through identification of informative texts and quotations [
13]. The codes were grouped into key themes derived from study objectives (deductively) and emerging from the transcripts (inductively) [
14].
Discussion
To our knowledge this is the first evaluation of an asthma education task-shifting intervention in Sub-Saharan Africa (SSA), in which asthma education is delivered by educators with no medical or nursing background. Patients and their parents expressed high levels of satisfaction and described the positive impact of asthma education on their knowledge levels, asthma symptoms and daily life. Families reported increased confidence to self-manage asthma attacks at home, resulting in reduced absence from school and work, and fewer emergency health facility attendances. The educators emphasized the importance of building a good rapport with the patient and their family, and pacing the delivery of information, considering the participants’ background educational level. Young people and their families appreciated the open and friendly approach of the educators, and the time and patience that were taken to ensure understanding and address all their questions. We found that asthma education can be delivered successfully by non-medical personnel, given adequate training, and ongoing support from clinical staff, and that this approach was popular with young people and their families.
Task shifting is an attractive strategy in a resource-limited setting such as Malawi. The shortage of health workforce in LMICs is a major obstacle to the delivery of good quality care for chronic non-communicable diseases (NCDs) [
9]. The WHO defines critical staffing shortage if a country has fewer than 2.5 health service providers (doctors, nurses and midwives) per 1000 population; 36 of the 57 countries identified as such are in SSA, with Malawi reporting two physicians and 28 nursing and midwifery personnel per 100,000 population in 2016 [
15]. Although task-shifting has been evaluated for several NCDs, the evidence for asthma is scarce [
9,
16]. One study in rural Cameroon reported improved outcomes for patients who received nurse-led asthma care, although 40% of patients had no follow-up data [
10].
In Malawi, task-shifting of HIV screening to non-medical cadres has been successfully deployed with lay counsellors delivering HIV counselling and testing with good programme outcomes [
17]. Health Surveillance Assistants (non-clinician health workers) have also been employed to deliver community case management of childhood illnesses; in common with our findings and others, the importance of ongoing support and supervision were highlighted in an evaluation of this scheme [
18,
19]. Also in common with our study, recognition by the community and positive feedback were also mentioned as motivating factors [
20].
In high-income settings, a small number of studies have evaluated peer- and lay-led complex asthma interventions for adolescents, suggesting a small improvement in asthma-related quality of life, although the effect on asthma control, exacerbations and adherence are unclear [
21]. Self-management education delivered to adults with asthma by trained lay people, resulted in comparable clinical outcomes to patients seen by primary care based practice nurses in the UK [
22]. Qualitative exploration of the experiences of these lay educators reinforced several of the points raised in our study; the need for comprehensive support and monitoring, particularly at the start of the programme, and the importance of training, with consideration of content, intensity, and interactive teaching methods [
23].
In the USA, asthma education delivered by trained lay volunteers to families of inner-city children with asthma, during an acute hospital admission, was associated with improved asthma management behaviours [
24].
Our qualitative sub-study sampled the experiences of a range of participants involved in the asthma education sessions, to facilitate triangulation of our findings. One limitation of our study could be that those agreeing to participate may have had a more positive view of the intervention; however, participants were purposively sampled with only two potential participants declining to take part, with the main reason given being time constraints. To ensure that participants felt comfortable to freely express their opinions, FGDs and interviews were facilitated by an independent researcher, with no previous connection to the RCT participants.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit
http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (
http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.