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ORIGINAL ARTICLE
Year : 2006  |  Volume : 1  |  Issue : 1  |  Page : 8-11
Asthma care: Structural foundations at primary health care at Al-Qassim region, Saudi Arabia


1 Allergy and Clinical Immunology at AL-Qassim General Hospital, Buridah, Saudi Arabia
2 Emergency Department, King Saud Military Hospital, Unaizah, AL Qassim, Saudi Arabia
3 Internal Medicine, Allergy and Clinical immunology at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Correspondence Address:
Emad A Koshak
Department of Internal Medicine, King Abdulaziz University Hospital, PO Box - 80215, Jeddah - 21589
Saudi Arabia
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DOI: 10.4103/1817-1737.25863

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   Abstract 

BACKGROUND: Proper structural foundations for asthma care at primary health care centers [PHCCs], are of essential importance, regarding its management. OBJECTIVE: To assess the adherence of PHCCs to the recommended structural foundation for asthma care. MATERIALS AND METHODS: 35 PHCCs were selected in a cluster random fashion. A questionnaire for structural standards was designed, based on the Saudi national protocol for the management of asthma (SNPMA). A physician and a nurse, each from PHCC, were trained for data collection. Structural facilities deficiency was arbitrarily classified into: least deficient (>75%), moderate to severe deficient (25-75%) and most deficient (<25%). RESULTS: The total population registered, was 131190 [urban: 85701 (65.4%), rural: 45489 (34.6%)]. Total registered asthmatics was 4093 [urban: 2585 (63.1%), rural: 1508 (36.9%)]. The asthma prevalence rate did not differ significantly between urban (3%) and rural (3.3%) areas . Structural facilities distribution for asthma care, did not significantly vary among urban and rural PHCCs and none of them fulfilled 100% of the desired standards. The least deficient, were the availability of asthma register and salbutamol, in its various forms. The moderately to severely deficient were the SNPMA, peak flow meter (PFM), nebulizer system, Theophylline and systemic corticosteroid. However, they were most deficient in trained doctors and nurses, record charts for Peak flow meter, spacer, educational material and inhalers of corticosteroid or cromoglycate. CONCLUSION: Proper structural foundations for asthma care at PHCCs, at AL-Qassim region, were below the desired national standards. They were most deficient in trained doctors and nurses, record charts for PFM, spacers, educational material and anti-inflammatory inhalers. Future health directorate strategies have to provide such beneficial interventions for proper asthma care.


Keywords: Asthma, primary health care, structural foundations.


How to cite this article:
AL-Haddad NS, Nour AR, Koshak EA. Asthma care: Structural foundations at primary health care at Al-Qassim region, Saudi Arabia. Ann Thorac Med 2006;1:8-11

How to cite this URL:
AL-Haddad NS, Nour AR, Koshak EA. Asthma care: Structural foundations at primary health care at Al-Qassim region, Saudi Arabia. Ann Thorac Med [serial online] 2006 [cited 2019 Dec 6];1:8-11. Available from: http://www.thoracicmedicine.org/text.asp?2006/1/1/7/25863


Globally, as a corollary to extensive researches, the quality of asthma care services[1],[2] has improved considerably and patients have themselves attested to these facts.[3] However, the development and organization of asthma services have not always met beneficial results to the patients[4],[5] and many of their needs are unmet.[6],[7]

In developed countries, the medical services for patients with asthma are relatively well established, with continuing researches contingent improvisations and further development of new model for improving care.[8],[9],[10] Despite these remarkable progresses in asthma care, this heterogeneous condition is still under diagnosed and under and/or over-treated.[11] Further, a body of researches worldwide, has identified several unmet needs of asthmatics.[6],[7],[12]

On the other hand, the rapidly developing Arabian Gulf countries are facing many challenges in particular, how to organize and provide cost effective, best quality care to patients with asthma, the prevalence of which is increasing, i.e., 4 to 33.7% and became as common as in the developed world.[13],[14] Likewise, there are few studies that have explored the magnitude of asthma problems in the Arab world. Moreover, only one study has addressed the crucial issues of asthma care pertaining to structural layouts at primary health care centers, in Saudi Arabia.[15]

Realizing the tremendous importance of proper structural foundations for asthma care at PHCCs, we have examined this issue in detail, in order to fill the structural gaps, by offering proper research-derived recommendations. We hypothesize that urban and rural PHCCs would have deficient structures, with special reference to delivery of asthma care to patients, who essentially tend to attend PHCCs.


   Methods and Materials Top


There were 142 PHCCs distributed uniformly throughout Al-Qassim region, which is located in the northern part of the central area of the Kingdom of Saudi Arabia. These provide comprehensive primary health care services to the primary care clients. For proper supervision and follow-up, these PHCCs were grouped under the umbrella of 16 regional supervising offices. Each of them supervises an average of 4-15 PHCCs. For this particular study, 35 PHCCs were selected in a cluster random fashion. This approximately constituted 25% of the PHCCs of Al-Qassim region. These 35 PHCCs were comprised of 23 rural, plus 12 urban PHCCs. The Study was Conducted in 2001.

The questionnaire

The standards of optimal asthma care, in terms of structural layouts, were defined in accordance to the recommendations of the latest Saudi national protocol for the management of asthma.[16] The PHCCs should fulfill 100% structural standards, in order to provide optimal care to asthmatic patients.

A preliminary questionnaire, which included the structural standards of asthma care, was designed. According to the structural standards, the following facilities must be available in each PHCC: 1) one well trained doctor and nurse in asthma care, 2) asthma register, 3) the national protocol for management of asthma, 4) educational materials in terms of leaflets, booklets and posters, 5) Peak flow meter, 6) PFM recording charts, 7) spacer, 8) nebulizer, 9) bronchodilators including salbutamol and methylxanthine, 10) anti-inflammatory agents, including corticosteroids in several forms and 11) sodium cromoglycate. In addition, there should be data regarding total registered population, registered asthmatic patients and deaths due to asthma.

The preliminary questionnaire was pretested by recruiting five PHCCs, after systematic randomization. The data were collected by the general practitioner, from each of the selected five PHCCs. The completed questionnaires were reviewed by the research team, in accordance with the structural standards. The research team identified some difficulties, in particular, the comprehension of questions and items for filling the questionnaires by the physicians. These problems were discussed with the GPs and accordingly some modifications and revisions were made in the final version of the questionnaire.

Data collection and analysis

A physician [n=35] and an active nurse [n=35] from each of the studied PHCCs, who were briefed about the survey, were selected for collecting the data. Besides briefing, they were further trained formally in techniques of data collection, at the continuous medical education and community services, Buriadah. The training sessions, included the important topic of structural standards of asthma care, health care quality assessment, research methodology and health care administration. However, tremendous emphasis was placed on noting down the structural standards of asthma services, in the questionnaire that is available at PHCCs.

The physicians and the nursing staff assigned at these PHCCs for collecting relevant data, examined the available structures meant for asthma care. They duly filled 35 questionnaires during March 2001 and returned to the investigators. The so collected data were once again checked for completeness. The data were entered into personal computers and Statistical Package for the Social Science (SPSS). Software version 10 was used for statistical analysis. Frequency distribution and chi square tests were used for analyzing the data. The P value of 0.05 or less was considered statistically significant.


   Results Top


The total population registered at the randomly selected PHCCs, was 131190. Saudis constituted 92.4% (n=121219), while non-Saudis were 7.6% (9971). Further, the distribution of population registered at urban PHCCs (n= 85701, 65.4%), was higher than the number of persons at rural dispensaries (n=45489, 34.6%) [Table - 1].

Moreover, the total numbers of patients with asthma, registered at the selected PHCCs, were 4093. Among them, Saudis were 3981 (97.3%), while non-Saudis comprised of 112 (2.7%) patients. The patients with asthma, registered at urban and rural dispensaries, were 2585 (63.1%) and 1508 (36.9%), respectively [Table - 2]. The overall prevalence rate of bronchial asthma was 3.1% of total registered cases. Further, it did not differ significantly between urban (3%) and rural areas (3.3%).

The distribution of structural facilities for the management of asthma, was not statistically significantly varied in urban and rural PHCCs [Table - 3][Table - 4]. Moreover, none of the primary health care centers, fulfilled 100% the desired standards of the structure. Based on the total frequency distribution, the structural facilities deficiency were arbitrarily classified into-least deficient (>75%), moderate to severe deficient (25%-75%) and most deficient (<25%). The least deficient structural facilities observed at both urban and rural PHCCs, were the availability of asthma register and Salbutamol, in its various forms. Furthermore, the moderately to severely deficient structural facilities were the national protocol for the management of asthma, peak flow meter, nebulizer system, Theophylline (oral and suppository) and corticosteroid (oral and injection). However, the PHCCs were most deficient structurally in trained doctors and nurses, record charts for peak flow meter, spacer, education material, corticosteroid inhaler and sodium cromoglycate.


   Discussion Top


Realizing the tremendous importance of proper structural foundations for asthma care at PHCCs, this work has examined this issue in detail, in order to fill the structural gaps, by offering proper research-derived recommendations.

Unfortunately, none of the PHCCs fulfilled adequately, the desired standards of the structure. Moreover, the distribution of structural facilities for the management of asthma, did not significantly vary statistically, between urban and rural PHCCs. This might reflect the overall lack of awareness in proper asthma care measures, rather than specific financial or cost deficits, found in the different locations of PHCCs. Any improvement in the implementation of the general structural measures will benefit the care of asthmatic patients.

Based on the total frequency distribution, the least deficient structural facilities observed at both urban and rural health centers, were the availability of asthma register and the Salbutamol in its various forms. Furthermore, the moderately to severely deficient structural facilities, were the national protocol for the management of asthma, peak flow meter, nebulizer system, Theophylline (oral and suppository) and corticosteroid (oral and injection). However, PHCCs were most deficient structurally, in trained doctors and nurses in asthma care, record charts for peak flow meter, spacer, education material and anti-inflammatory inhalers (corticosteroid and sodium cromoglycate). This lack of essential supplies and measures, reduces efficient management of asthma. Based on current asthma management guidelines, optimal asthma care includes the following: development of asthma management guidelines, training of medical staff to identify and to follow asthma cases, wider use of inhaled corticosteroids, PFM monitoring, patient education programs and other factors.[16],[17] These national and international guidelines are a major step and cornerstone, in the proper management of asthma. Studies in many countries have shown that utilization of asthma management guidelines improves asthma management and their implementation among general practitioners is critical to improve quality of life among asthma patients in general.[18],[19],[20]

In the kingdom of Saudi Arabia, the national protocol for the management of bronchial asthma developed since 1995 and was updated in 1998 and 2000, but few primary health care doctors and nurses were trained on using it.[16] The availability of the national protocol and training a doctor and nurse from each PHCCs, will encourage the establishment of an asthma clinic, in each center.

The PFM can help in diagnosing and monitoring asthma, by demonstrating variability over 15%, between the morning and evening peak expiratory flow rate.[16],[17] Like other studies, the present study revealed that PFM is lacking in almost all PHCCs and hence, so many of the asthmatics were misdiagnosed and mistreated.[12],[15]

Another major deficiency found in this study, was the availability of asthma medications, particularly the anti-inflammatory inhalers. Asthma is a chronic inflammatory disease and the role of inhaled anti-inflammatory drugs in controlling persistent asthma, can not be overemphasized.[16],[17]

Patient education is an essential component of successful asthma management and an array of effective and innovative asthma education programs have been developed.[22] It helps patients gain the motivation, skill and confidence, to control their asthma.[23],[24]

In conclusion, this study had reveled that proper structural foundations for asthma care at PHCCs at AL-Qassim region, were below the desired national standard. The PHCCs were most deficient in trained doctors and nurses, record charts for PFM, spacers, educational material and anti-inflammatory inhalers. Future health directorate strategies and specific measures, have to provide such beneficial interventions for proper asthma care. Similar investigational audit is continuously needed, in order to fill the structural gaps, by offering proper research-derived recommendations.

 
   References Top

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8.Usherwood TP, Barber JH. Audit of process and outcome in a mini-clinic for children with asthma. Fam Pract 1988;5:289-93.  Back to cited text no. 8  [PUBMED]  
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12.Worstell M. Asthma: individual patient perspective and current unmet needs. Clin Exp Aller 2000;30:11-5.  Back to cited text no. 12  [PUBMED]  
13.The International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Worldwide variation in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema: ISAAC. Lancet 1998;351:1225-32.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Alfrayh A, Shakoor Z, Fakhri E, Koshak E, Al Nameem S, Al Ageb Amin, et al . A 17 year trend for the prevalence of asthma and allergic diseases among children in Saudi Arabia. Curr Pediat Res 2004;8.  Back to cited text no. 14    
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16.The National Protocol for the Management of Asthma. Members of the Saudi national scientific committee for the diagnosis and management of bronchial asthma: Al- Frayh A, Khoja T, Al-Majed S, Al- Rayes H, Neyaz A, Koshak E, et al , editors. 3rd ed, Ministry of Health: 2000.  Back to cited text no. 16    
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18.Neville RG, Hoskins G, Smith B, Clark RA. Observations on the structure, process and clinical outcomes of asthma care in general practice. Br J Gen Pract 1996;46:583-7.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]
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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]

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