|Year : 2013 | Volume
| Issue : 1 | Page : 27-32
Asthma control among patients in Uyo South-Eastern Nigeria
Victor Aniedi Umoh, John U Ekott, Mfon Ekwere, Obeten Ekpo
Department of Internal Medicine, University of Uyo Teaching Hospital, Uyo Akwa Ibom State, South-Eastern, Nigeria
|Date of Web Publication||17-Aug-2013|
Victor Aniedi Umoh
Department of Internal Medicine, University of Uyo, Uyo Akwa Ibom State, South-Eastern
Source of Support: None, Conflict of Interest: None
Background: The prevalence of asthma is increasing in the developing world. Asthma, management guidelines have been instituted to provide recommendations for the optimal control of asthma. This study evaluated the current level of asthma control as reported by the patients, which may be a reflection of adherence to guidelines. Materials and Methods: Asthma patients referred to a respiratory diseases clinic were recruited for the study. The asthma control test (ACT) was administered on the patients and data were also obtained for medication use and disease monitoring. A total ACT score of <20 signified poor control. Results: Out of 78 patients, 70 completed the survey (89.7%). The average age of patients was 46 ± 18 years (mean ± standard deviation). The average ACT score was 14.4 ± 4.8 82.9% of patients had poor control. 57.1% of patients who perceived their asthma to be well or totally controlled were objectively assessed to be poorly controlled. More than half of the patients used short acting β2 agonist alone and only 20% used inhaled corticosteroids for maintenance therapy. Thirty eight patients made unscheduled emergency room visits in the past 12 months and 68.8% could not use their inhaler devises well. Emergency room visits (odds ratio [OR] 9.5) and poor inhaler technique (OR 18.9) was independent predictors of poor asthma control. Conclusion: The current level of asthma control among patients in Uyo is below guideline recommendations. Management of patients did not appear to follow guideline recommendations and patients tend to over-estimate their disease control.
Keywords: Asthma, control, guidelines, recommendations
|How to cite this article:|
Umoh VA, Ekott JU, Ekwere M, Ekpo O. Asthma control among patients in Uyo South-Eastern Nigeria. Indian J Allergy Asthma Immunol 2013;27:27-32
|How to cite this URL:|
Umoh VA, Ekott JU, Ekwere M, Ekpo O. Asthma control among patients in Uyo South-Eastern Nigeria. Indian J Allergy Asthma Immunol [serial online] 2013 [cited 2020 Jan 24];27:27-32. Available from: http://www.ijaai.in/text.asp?2013/27/1/27/116611
| Introduction|| |
Asthma is a world-wide problem, with an estimated 300 million affected individuals. The global prevalence of asthma is estimated in the range of 1% to 18% of the population in different countries.  In Nigeria, the prevalence of asthma is not known for certain but several surveys using asthma symptoms as surrogates for asthma have come up with estimates of between 7% and 14% while the prevalence of physician diagnosed asthma ranges between 1.8% and 6%. ,,,,
In an attempt to tackle the problem of asthma, the United States national heart, lung and blood institute and the world health organization in 1997 convened a workshop on asthma. The workshop report presented a comprehensive plan on the management and prevention of asthma; the global initiative for asthma (GINA).  This initiative has come up with guidelines, which are regularly updated and the information widely disseminated to health workers and patients.
Previously asthma was classified by disease severity based on symptoms, airflow limitation and lung function. The use of severity in classifying asthma patients has certain limitations such as a poor value in predicting what treatment was most appropriate and the sort of response to expect.  Disease severity is not a constant feature of an individual patient's asthma but varies over time. Therefore, periodic assessment of asthma control is more relevant to asthma management. In the 2008 GINA guidelines asthma classification was revised from the previous system, which utilized disease severity to the use of control of asthma. Asthma control may be defined in several ways: Generally, diseases control may indicate disease prevention, or even cure. However, in asthma, where neither of these is currently possible, it refers to control of the clinical manifestations of disease. 
The control of asthma symptoms is a realistic goal and studies have shown that this can be achieved in most asthma patients  leading to a higher quality of life.  In spite of this, the control of asthma is generally poor. The Asthma Insights and Reality in Europe study reported persistence of day time symptoms of up to 46% among asthmatics under treatment.  Surveys from other parts of the world reveal a similar picture of suboptimal control. , Local studies are in agreement with the world-wide picture with more than two- thirds of patients having sub-optimal control in some surveys. ,
Based on evidence from previous studies and anecdotal observations of asthma patients referred to our clinics it appears that there is generally poor control among our patients. This survey was carried out to determine the level of control among asthma patients attending the respiratory diseases clinic in the University of Uyo Teaching Hospital (UUTH), and to evaluated factors associated with poor control.
| Materials and Methods|| |
This study was conducted in the respiratory diseases clinic of UUTH. This is a public hospital located in the capital of Akwa Ibom State, South Eastern Nigeria. This hospital provides secondary and tertiary health-care services for the people of Akwa-Ibom and the neighboring states. The respiratory diseases clinic receives referrals from the Hospital's general out-patient clinics, the general medical out-patient clinic and from other primary and secondary health-care facilities within and around the state.
The survey was conducted over a 12 month period (June 2011-May 2012) in this period 511 patients were referred to the respiratory diseases clinic for various respiratory conditions of which 102 (5.0%) were referred with a diagnosis of asthma. The diagnosis of asthma was confirmed in the clinic by demonstrating the presence of clinical features of asthma in the history and reversible airflow limitation by spirometry.  Clinical features taken into consideration included; recurrent episodes of shortness of breath, chest tightness, cough, and wheezing, which is usually worse at night, during the cold rainy season or by accidental allergen exposure. Airflow limitation was confirmed by the ratio of forced expiratory volume in 1 s (FEV1) and forced vital capacity <0.70 while reversibility was confirmed by demonstrating up to 12% improvement in FEV1 from baseline 30 min after administering 200-400 ΅g of salbutamol by inhalation. All lung function measurements were carried out by the investigators using the same spirometer (Spirolab III manufactured by Medical International Research). All newly referred asthma patients who consented to participate were recruited for this study.
The questionnaire included the asthma control test (ACT).  This is a five question test. Each question has 5 options with scores from 1 to 5. The total score ranges from 5 to 25 with a higher score indicating better control. The ACT assesses asthma control over the previous four weeks. The questionnaire also contained questions on demography, smoking habits, medications, disease monitoring, and comorbidities. The questionnaire was translated into the local language (Ibibio) and back translated for consistency. Translations of ACT into local languages have been verified for assessment of asthma control in previous studies. , The local language version was administered on patients who had a poor understanding of the English version.
Data were analyzed using SPSS statistical software version 18. Total score was calculated for all respondents and the patients were categorized into 3 groups; not controlled (total ACT score < 20) well-controlled (total ACT score 20-24) and total control (total ACT score of 25). Any patient with a total score above 19 was deemed to have good control.  Categorical variables were presented on frequency tables and the relationship between the variables and level of control was examined using a contingency table. Independent predictors of poor control were evaluated using binary logistic regression. P < 0.05 were considered statistically significant.
| Results|| |
Seventy eight patients were invited to participate in this survey. Eight of them did not consent to the survey leaving seventy participants (89.7% participation). There were 38 (54.3%) females and 32 (45.7%) males. The age of the patients ranged from 20 to 87 years with an average of 46 ± 18 years. There was a bi-modal distribution of age with age intervals of 31-40 and above 60 years having the highest number of patients. A majority of the asthmatics (48.6%) had tertiary education and as such most of them (68.6%) worked in the public service. There was a high rate of unscheduled emergency room visits with 38 (54.3%) of the asthmatics making at least one emergency room visit within the last 12 months. A majority of the patients (65.7%) reported consistent exposure to possible allergens with dust and kerosene fumes being the common allergens that they were exposed to. 37.1% of the respondents used their medications frequently (≥ three times a day) and just 22 (31.4%) could use their inhaler device well. In terms of diagnosis and disease monitoring, 22 (31.4%) had spirometry carried out in the course of their initial evaluation prior to being referred, while only two patients owned and used a peak flow meter for regular monitoring of their asthma [Table 1].
More than half of the patients used short acting β2 agonist (SABA) alone for maintenance therapy (oral SABA; 34%, inhaled SABA 23%) The use of inhaled corticosteroids (ICS) either alone or combined with a long acting inhaled β2 agonist (LABA) was not common (ICS alone; 6%, ICS and LABA combination; 14%) [Table 2].
The total ACT scores ranged from six to twenty five with an average of 14.4 ± 4.8 (mean ± standard deviation). 82.9% of patients had poor control, 14.3% were well-controlled and only 2.9% had total control of their asthma symptoms [Table 3]. Thus, 17.2% of patients had good control of their asthma (total score ≥20) [Figure 1].
|Table 3: Control of asthma symptoms among asthma patients using the ACT questionnaire |
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|Figure 1: Asthma control among respondents using the asthma control test; a majority of the patients had poorly controlled asthma|
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Correlates for poor asthma control
A contingency table was constructed to examine the relationship between patient characteristics and poor asthma control using the Chi-square test for independence (χ2 ). All respondents above 60 years were found to have poor control; however, this did not attain statistical significance. Significantly fewer females had poor control compared to males (73.7% vs. 93.8%). All unskilled workers, respondents with no education and no employment had poor asthma control. However, this was not statistically significant. A Previous emergency room visit, a subjective assessment of poor control, not using a peak flow meter for regular disease assessment, not using an inhaled bronchodilator for maintenance therapy, the use of systemic bronchodilators, and a poor inhaler technique were significantly associated with poor asthma control. More than half of the respondents (57.1%) who perceived their asthma to be well or totally controlled were objectively assessed to be poorly controlled [Table 4].
Predictors of poor control
Direct logistics regression was performed to assess the impact of a number of factors on the likelihood that respondents would be classified as having poor control. The model contained five independent variables (gender, prior emergency room visit, routine use of a peak flow meter, regular use of medications, and inhaler technique). The full model containing all predictors was statistically significant; χ2 (5, N = 70) =38.7, P < 0.001. The model as a whole explained between 42.5% (Cox and Snell R square) and 70.8% (Nagelkerke R square) of the variation in asthma control status and correctly classified 91.4% of cases with a sensitivity of 96.0% and specificity of 66.7%. The positive predictive value of the model was 93.3% while the negative predictive value is 80.0%. As shown in [Table 5] only prior emergency room visit and inhaler technique made unique statistically significant contributions to the model. A poor inhaler technique was the most significant predictor of poor asthma control; odds ratio (OR) =18.9, 95% confidence interval = 2.3-155.6.
| Discussion|| |
Chronic non-communicable diseases (NCD) are often thought to be health problems of significance only in developed countries. In reality, only 20% of NCDs deaths occur in high income countries-while 80% occur in developing countries, where most of the world's population lives. It is expected that the burden of NCDs will increase in the developing world and account for up to 25% of deaths by 2015.  Unfortunately disproportionately more attention is paid to communicable diseases thus effectively relegating NCDs. The prevalence of asthma is on the increase world-wide with a steeper rise in developing countries. 
This study has demonstrated that despite the availability of effective therapy for asthma, the control of asthma is sub-optimal among our patients and falls short of the GINA guideline recommendations. Over 80% of our patients had poorly controlled asthma with only 2.9% having total control. The result of this survey is supported by data from previous surveys in other parts of the world , and in Nigeria. Desalu et al. in a survey of asthma patients in Ilorin central Nigeria observed poor control among 69% of the patients with a significant association between poor inhaler technique, under- utilization of ICS and the use of systemic steroids with uncontrolled asthma.  Ozoh et al. demonstrated poor control among 52% of patients in Lagos. 
A key finding in this study is the discrepancy between patient's subjective assessment of their control and the objective assessment by ACT. Patients tended to underestimate the severity of their asthma and overestimated the control while tolerating a high rate of asthma symptoms. Over half of the patients that perceived their asthma as being well-controlled actually had poor control and the data from previous studies support this finding. ,, The reasons for this may be the patients have adapted to their condition and are ready to settle for a life with some symptoms. 
Spirometry is an essential tool in the initial diagnosis of asthma,  categorization of disease severity  and for prognostication.  Less than one-third of the patients had any lung function measurement taken in their work-up for diagnosis and for disease monitoring and only two patients owned a peak flow meter. This is in-spite of the fact that clinical assessments alone may lead to under-diagnosis of asthma.  The poor utilization of lung function measurement in patient management in this study may be because physicians do not always follow guideline recommendations in making asthma diagnosis and this has been shown to be commoner among non-specialists. 
Emergency room visit is a pointer to poorly controlled asthma. Several studies have demonstrated an association between unscheduled urgent care visits and poor control. , This survey demonstrated a significant association between emergency room visits and poor control. More than half of the patients reported an unscheduled emergency room visit within the previous 12 months. The rate of emergency room visits was higher than that obtained in surveys in Europe  and in the Middle East  but is consistent with the rates obtained from a survey in South-West Nigeria. 
Asthma exacerbations may be caused by a variety of triggers. The avoidance of these triggers may improve the control of asthma and reduces medication needs. In this study, two-thirds of the patients reported continued exposure to potential triggers. Several other studies have demonstrated a similarly high level of continued exposure to triggers and that this is associated with frequent disease exacerbation and poor control. ,
The goal of asthma treatment is to achieve and maintain clinical control. Asthma being a chronic inflammatory disorder of the airway requires the daily use of anti-inflammatory medications to control the clinical manifestation of the disease.  ICS are currently the most effective anti-inflammatory medications for the treatment of persistent asthma. Studies have demonstrated their efficacy in the long-term management of persistent asthma. ,,,, Globally, the use of ICS varies from as low as 5% in the Middle-East  to as high as 62% in North America.  Only 20% of patients used inhaled steroids either alone or in combination with a LABA in this survey. This low utilization of inhaled steroids is supported by data from other studies in Nigeria. Oni et al. in a previous survey of asthma patients in Ile-Ife found inhaled steroid use to be 28%.  This low utilization of ICS may be due to poor prescription practice among physicians in Nigeria. 
Despite guideline recommendations, more than half of the patients routinely used only SABA either orally or inhaled for the long-term control of asthma. The high dependence on SABA is supported by data from some other studies. In the asthma insights and reality study in the United Arab Emirates 67% of the patients used SABA routinely while 57% of them believed that SABA was the most effective medication for controlling their asthma.  In South west Nigeria, 70% of the patients surveyed used SABA alone for asthma treatment.  The frequent use of SABA among asthmatics may be explained by the fact that a lot of patients do not see asthma as a chronic disease. 
Inhaled medications are recommended for the control and relief of asthma symptoms because of their reduced side-effects. The efficacy of inhaled medication is dependent on the proper use of such devices. In this study, poor inhaler technique (OR 19) and emergency room visits were significantly associated with poor asthma control after controlling for the effects of medication use, disease monitoring and gender. Other studies have demonstrated a high prevalence of poor inhaler technique and an inverse relationship with good disease control. 
In conclusion, this study has demonstrated a wide gap between goals of asthma control and the reality among our patients. Guideline recommendations concerning pathophysiology of the disease, assessment of disease severity, diagnostic techniques, patient monitoring, and patient education are not adhered to by the managing physicians. The patients appear to be complacent about what is achievable in terms of asthma control and accept a life with symptoms as being part of being asthmatic.
We would recommend that more resources should be channeled into educating physicians and patients on the current recommendations on the management of asthma so as to improve the quality of care our patients receive.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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