Unmet needs in asthma treatment in a resource-limited setting: findings from the survey of adult asthma patients and their physicians in Nigeria

Introduction The prevalence of asthma in our society is rising and there is need for better understanding of the asthma patients’ perception and treatment practice of physicians. The study was aimed at determining asthma attitudes and treatment practices among adult physicians and patients in Nigeria, with the goal of identifying barriers to optimal management. Methods To assess asthma attitudes, treatment practices and limitations among adult physicians and patients in Nigeria, a questionnaire survey was conducted among 150 patients and 70 physicians. Results Majority (66.7%) of the patients reported their asthma as moderate to severe, 42.7% had emergency room visit and 32% had admission due to asthma in the previous 12 months. Physicians and patients perceptions significantly differed in the time devoted to educational issues (31.4% vs.18.7%) and its contents: individual management plan (64.3% vs.33.3%), correct inhaler technique (84.0% vs.71.0%), medication side effects (80.0% vs.60.0%) and compliance 100% of time (5.7% vs. 18.7%). Patients reported that non-compliance with medication causes increased symptoms (67.0%), exacerbations (60.0%), bronchodilator use (56.0%), urgent physician visit (52.0%) and hospitalizations /ER visits (38.7%). Asthma medication in patients caused short term (10.7%) and long term side effects (20.0%). Due to side effects, 28.0% skipped and stopped their medications. Most physicians (85.7%) and patients (56.0%) agreed on the need for new medication options. The need for new medication in patients was strongly related to asthma severity, limitation of activities, side effects, cost and lack of satisfaction with current medication. With the exception of pulmonologists, physicians did not readily prescribe ICS and their prescriptions were not in line with treatment guidelines. Conclusion This study has highlighted the gaps and barriers to asthma treatment which need to be addressed to improve the quality of care in Nigeria.


Introduction
Asthma affects about 235 million people worldwide [1]. The incidence of asthma has been growing over the past 30 years due to changing environmental factors, particularly in the low-and middle-income countries that are least able to absorb its impact [1].
Asthma causes an estimated 250,000 deaths annually (1 in 250 deaths worldwide) [1,2]. In addition, the World Health Organization estimates that around 15 million disability-adjusted life years (DALYs) are lost annually through this disease [2]. Fifty years ago asthma was uncommon in Nigeria, however recent reports from different parts of Nigeria have shown a prevalence of adolescent and adult asthma in excess of 10% and a rising trend in the prevalence of asthma [1,[3][4][5][6][7] .The increase in burden the asthma has been attributed to environmental factors such as urbanization, industrialization and adoption western life style [8]. The International Study of Asthma and Allergies in Childhood in children and the European Community Respiratory Health Survey in adults have greatly increased our understanding of epidemiology of asthma worldwide [9][10][11]. The Asthma Insights and Reality (AIR) surveys further gave more understanding into the actual variations in symptom severity and control of asthma and the current state of asthma management with respect to the GINA guidelines [12].The AIR study found that significant proportion of patients continue to have symptoms , lifestyle restrictions and require emergency care.
There is also a poor correlation between patients-perceived severity of asthma and objective assessment of severity on the basis of GINA criteria. The current level of asthma control worldwide falls far short of the goals for long-term management in international guidelines. [12]. Considering the report of AIR study which was attributed to gaps in the physician management and patient understanding of asthma causes and treatment, the Global Asthma Physician and Patient (GAPP) Survey [13] was designed to build on the findings from the AIR study, to uncover asthma attitudes and treatment practices among separate groups of physicians and patients, with the goal of identifying barriers to optimal management. In view of the rising prevalence of asthma in our society there is need for better understanding of the asthma patients' perception and treatment practice of physicians. There is paucity of data on asthma attitudes and treatment practices among physicians and patients in Nigeria. The initial global survey excluded most developing countries and no similar study has been done in resource poor settings. Our study therefore was aimed at exploring the asthma attitudes and treatment practices among adult physicians and patients in Nigerian hospitals, with the goal of identifying barriers to optimal management.

Study design and population
This survey was a cross sectional study conducted from 30th March to 24th September, 2012. The study settings were six tertiary and three private (primary care) hospitals in five out of the six geopolitical regions of Nigeria. Nigeria is in the West African subregion and it is the most populous nation in Africa. The GAPP study [13] protocol was adopted for this study and modified to suit our local setting. The modifications were in terms of administration of the survey instrument, sample recruitments and the types of health care providers recruited for the study, as nurses were not closely involved with treating Nigerian patients with asthma.

Sample size
The minimum sample size was arrived at using Cochran's formula n = Z 2 pq/d 2 , n = Sample Size, p = prevalence of asthma among adults in Ilorin, Nigeria which is 15.2% [3]. The q = (1 -p), Z = standard normal deviation usually set at 1.96 which correspond to the 95% confidence interval. d = degree of accuracy desired usually set at 0.05.The calculated minimum sample size was 198. The population of adult asthma patients seen in the participating hospitals in the preceding one year before the study was 410.
However, since this sample size exceeds 5% of the eligible population (400 x 5% = 20.0), Cochran's correction formula was used to calculate the final sample size. These calculations are as follows: n/ (1+n/410) = 134. Assuming a response rate of 90 %, a sample size of 147 was desired for adult patients. All eligible physicians working in participating hospitals and who met the inclusion criteria were recruited for the study.

Patients and physicians selection
The inclusion criteria for patients were: asthma patients attending participating hospitals must be least 18 years of age and their clinical diagnosis of asthma made at least 6 months prior to the Page number not for citation purposes 3 study. Patients with cognitive impairment, a severe exacerbation of asthma, or co-morbid chronic pulmonary disease (e.g., emphysema, chronic bronchitis, or bronchiectasis) were excluded from the study.
For the physicians, the inclusion criteria to be eligible for recruitment were: working in the department of family and internal medicine, give written consent to participate in the study, practicing medicine for 3-30 years; sees at least three adult asthma patients per week; and writes at least one prescription for asthma medications per week. The investigators screened eligible patients and informed them about the study. The patients and physician who gave their consent and met the inclusion criteria were also recruited as study participants.

Survey instrument
The questionnaire used in the study was a modification of the GAPP Survey questionnaire [13]. It was administered in English language, the official language in Nigeria. The questionnaire was pretested before use on 10 doctors and 10 patients in one study site to ensure the wording and content of the questions were widely understood and appropriate mode of administration of questionnaire was adopted. The questionnaire included items asking physicians and patients respondents to provide demographic information and answers to questions on the asthma diagnosis and symptoms, communication with their respective patients or physicians, resource utilization, experience with asthma medications, side effects from asthma medications, concern and awareness of side effects, treatment compliance and interest or desire for improved treatments. The patients and physicians were allowed to complete their questionnaire to ensure anonymity and guaranteed the confidential nature of the survey. Patients who had difficulty in completing the questionnaire were interviewed face-to-face by a trained interviewer who translated the items in the questionnaire into their native language. This mode of data collection was adopted to prevent exclusion of illiterate or patients with no formal education and to obtain the most representative sample from each participating hospitals.

Data analysis
The questionnaires were reviewed manually for consistency and appropriate coding prior to data entry. The data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 15 (SPSS Inc. Chicago IL, USA). Descriptive and frequency statistics were obtained for the variables of interest.
Chi square was used to test for statistical significance between categorical variables. Stratified analysis was performed to determine the relationship between impact of asthma, symptoms control, impact of medication side effect, level of satisfaction with current medication and the desire for new treatment options. All variables found to be significant were entered into bivariate analysis and Spearman's correlation coefficient was obtained. A P value of <0.05 was considered to be statistically significant.

Results
We interviewed 150 patients and 70 eligible doctors comprising of family physicians (FP)/ general practitioners (GP) and specialists (i.e. Internist, pulmonologists) .Of the 150 patients, 68% were females. General characteristics of the participating physicians and patients are shown in Table 1.

Impact of asthma and lack of symptom control
In this study, 33.3% of patients described their asthma severity as mild, 50.7% as moderate and 16.0 % as severe. Almost 18.7 % reported that asthma reduced their activity a great deal and 44.0% reported that they are somewhat limited by it. During the previous 12 months, 52.0% visited their physician for urgent care, 42.7% went to the hospital emergency room and 32.0% were admitted to hospital as a result of asthma ( Table 2).

Levels of asthma education
On their perception of asthma education, 38.6 % of physicians and

Treatment compliance and symptoms
The patients were questioned about the percentage of the time they  Table 4). Physicians are least satisfied with the availability and side effects of ICS ( Figure 5).

Discussion
The results of our study shows that the perception of physicians and In this study, asthma had a serious impact on the patients as 66.7% of them described their asthma as moderate to severe and 62.7 % reported a limitation of activity due to the disease and almost half of the patient made unscheduled visits to their doctor or visited the emergency room for asthma attack. This is an indication of lack of disease control in a significant proportion and this finding is in Page number not for citation purposes 5 keeping with the GAPP and other previous studies in Nigeria [13][14][15][16]. The high level of uncontrolled asthma is an indication of low quality of asthma care in the country which responsibility primarily rest on the physicians, partly on the patients and the healthcare system.
This study has exposed the low level of asthma education in Nigeria as corroborated by both the physicians and patients as one third of the physicians and one fifth of patients reported that half of the clinic visit was devoted to educational issues. In addition to poor level of education, we also observed a significant difference in their when the physicians are running very busy clinics [13,18]. Lack of support group may also have contributed to low level of asthma education as they are known to offer additional patient support and reinforcement of key educational messages which are very important to overall satisfaction and outcome [19].
More than 70% of the patients were unaware of short and long term side effects of ICS and that physician tend to underestimate the lack of awareness among the patients. This result is in contrast to GAPP study where one third (31%) of patients were unaware of long term side effects [13]. In this same GAPP study, the physicians equally underestimated the lack of awareness of the side effects among patients [13]. Our data also showed that less than one in four experienced the side effects of ICS and this may be attributed to lack of awareness and ability to recognize the side effects. GAPP and other studies found a strong correlation between side effects and the levels of treatment compliance [13,20,21].
With regards to treatment compliance, we found that about one in five patients (18.7%)  This study also found that most physicians believed inhaled corticosteroids (ICS) are the "gold standard" treatment for asthma.
Inhaled corticosteroids are essential for achieving these goals and managing patients with persistent asthma over the long-term [1,2]. Another reason for request for a new therapy is the erroneous belief that that ICS does not appear to significantly modify the course of the disease and are not curative, because asthma symptoms and inflammation rapidly recur when the treatment is discontinued and Page number not for citation purposes 6 this is a cause of concern as many patients who are also afraid of being addicted to the medications [24].The side effects of ICS are also causes for concern among the physicians in this study. The safety of long-acting beta-agonists (LABA) in the treatment of asthma has been a source of concern [25]; however recent metaanalysis has shown that when it is administered concomitantly with ICS mortality is drastically reduced. [26]. ICS that meet the demands of both physician and patients will improve medication compliance and rate of physician prescription.
The strength of this study is that it was conducted in five out of the

Conclusion
In conclusion, this study has highlighted poor medication compliance which is related to side effects, lack of patients' physician communication, poor prescription practices and lack of satisfaction with current medication as potential barriers to asthma treatment. These barriers often lead to poor asthma management and high prevalence of uncontrolled asthma, increased health resources utilization and cost of management in a large cohort of patients [27].

Competing interests
The author(s) declare that they have no competing interests'. The authors alone are responsible for the content and writing of this article.

Acknowledgments
The authors thank the postgraduate residents in the various centers for their contributions to this study.       Admitted to Hospital 32.0

Satisfaction with the current medication
Not satisfied about potential side effects +0.35 +0.31 0.013