Factors affecting levels of Asthma control in patients presenting to Kenyatta National, Thika and Mbagathi Districts Hospital
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Asthma is a common chronic inflammatory disease of the airways characterized by episodic airway narrowing and obstruction. Its prevalence has been noted to be on the increase both locally and worldwide. Asthma control, the reduction of the clinical features of the disease by use of adequate pharmacotherapy and environmental modification, forms one of the principal goals .of asthma management. Achievement of this goal, however, remains elusive with abundant evidence revealing that poor levels of control are being achieved in both developed as well as developing countries. These poor levels of control have been linked to a variety of patient related, treatment related, environmental and socloeconome factors. These factors remain unidentified in our setting. Objectives: The study was carried out with the objectives of determining the factors associated with suboptimal asthma control in children presenting to the treatment services of three large public hospitals in Kenya and assessing the perceptions of these children's parents! guardians of asthma control in their children. Methodology A cross- sectional survey of asthmatic children aged 1 to 14 years presenting to Kenyatta National (KNH), Thika District (TDH) and Mbagathi District Hospitals (MDH) was carried out. Children with a diagnosis of asthma made three or more months prior were recruited in the study on presentation to these hospitals. Their recruitment was done on their visits to the routine continuity clinics or when receiving urgent care for asthma exacerbations. Each child's asthma control status over the period of the two weeks preceding recruitment into the study was determined by questionnaire interviews. Children were either designated to be sub-optimally controlled if their asthma was partially controlled! uncontrolled or optimally controlled, if they had well controlled asthma. Exposure to various putative factors affecting control was then explored by questionnaire interviews of the children's caregivers. Analysis was performed to determine the odd's ratios and confidence intervals for individual factors. Multivariate analysis with binary logistic regression was then performed to identify factors that independently affected control. Open ended questions were also used to elicit parents' perceptions regarding asthma control in their children. Results: 135 children aged between 1 and 13 years were recruited. 78 of these were sub-optimally controlled while the remaining 57 were optimally controlled. In the univariate analysis, the presence of persistent symptoms of asthma prior to diagnosis, current symptoms of allergic rhinitis, failure to inform parents of their children's asthma control during their last clinic visit, poor adherence to controller medications, lack of an alternate caregiver to administer inhaled medication, living in a house with 4 or less rooms, lower family lhcome, exposure to cigarette smoke, a damp environment in the home and inability to identify exposure to cold weather as a trigger of exacerbations were all associated with sub-optimal asthma control. Independent predictors of sub optimal asthma control from multivariate analysis included the presence of persistent symptoms prior to the diagnosis of asthma (AOR 5.30; 95% C11.79, 15.69 P value = 0.003); not informing parents of their child's level of control during their last clinic visit (AOR 4.35; 95%CI 1.45 - 12.5, P value = 0.009), exposure to second hand tobacco smoke at home (AOR 3.47, 95%CI1.27 - 9.49, p value = 0.015), dampness at home (AOR 3.80; 95%CI 1.17, 12.32 p = 0.026) and inability to identify cold weather as a trigger factor (AOR 3.70; 95%CI1.54,9.09 p value = 0.004). Parents of sub-optimally controlled children were 25 (95%CI10, 50.5, P value = <0.0001) times more likely to incorrectly identify their children's level of control. Qualitative analysis of parents responses regarding their perceptions of asthma control revealed that most parents were using the occurrence of asthma exacerbations to determine control more that the recurrent daily symptoms. Conclusion: Sub-optimally controlled asthma was independently associated with (1) the presence of persistent symptoms of asthma at diagnosis, (2) lack of communication of the child's level of control to the parent on the last visit, (3) presence of a member of the household who smokes, (4) exposure to dampness in the home environment and (5) inability to identify cold weather as a trigger. Caregivers of sub-optimally controlled children tend to overestimate their children's level of control and report satisfaction with their child's level of control based predominantly on the occurrence of exacerbations rather than recurrent daytime or nighttime symptoms. Recommendations: Regular assessments of children's level of control and adherence to therapy to should be introduced during routine clinic visits. Adequate communication of guideline derived levels of control should be coupled with caregiver education to ensure that parents actively partner with health care personnel in ensuring control in their children.