Assessment of inhaled corticosteroids use and associated factors among asthmatic patients attending Tikur Anbessa Specialized Hospital, Ethiopia

A prospective cross-sectional study was conducted at the chest clinic of TASH from 1 May to 31 September 2014. TASH is located in Addis Ababa, the capital of Ethiopia, and it is the largest hospital in the country providing a tertiary level care.

All patients with persistent asthma of duration greater than 1 year were included. Patients were excluded if they were <18 years of age or had one or more of the following comorbidities: congestive heart failure, other lung disease [including but not limited to chronic obstructive pulmonary diseases (COPDs), cystic fibrosis, and interstitial lung disease], or other medical conditions, such as severe anemia or malignancy, that could have made categorization of asthma severity difficult.

All asthmatic patients who attended the clinic for their regular follow-up during study period and fulfilled inclusion criteria were included in the study summing up a total of 131 patients. Eight physicians (four fellows and four residents) working at the chest clinic were requested to fill semi-structured questionnaires for qualitative data.

Data were collected through patient interview using a semi-structured questionnaire comprising socio-demographic characteristics, disease characteristics, ICS use, and knowledge and attitude towards asthma and ICS. The questionnaires were adapted from previous studies and appropriate modifications were made to serve our purposes [10, 11]. In addition, the charts of the patients were also reviewed particularly to generate information pertaining to medication history. Data from physicians was collected by using self-administered semi-structured questionnaire focusing their perspectives and experiences on patients’ ICS use. Severity of asthma was determined by using GINA criteria [2] such as frequency of symptoms in a week, frequency of nighttime awakening symptoms in a past month, interference with normal activity, the use short acting β₂ agonist and lung function. Accordingly, mild persistent asthma was defined as occurrence of symptoms >2 days/week but not daily or occurrence of nighttime awakening symptoms three to four times a month or the use of short acting β₂ agonist >2 days/week but not daily, and not more than 1× on any day with minor limitation and forced expiratory volume in 1 s (FEV₁) >80% predicted. Moderate persistent asthma was defined as occurrence of symptoms daily or occurrence of nighttime awakening symptoms >1×/week but not nightly or the use of short acting β₂ agonist daily with some limitation and FEV₁ >60% but <80% predicted. Severe persistent asthma was defined as occurrence of symptoms throughout the day or occurrence of nighttime awakening symptoms nightly or the use of short acting β₂ agonist several times per day with extreme limitation and FEV₁ <60% predicted.

The regimen of ICS recommended for the patient is reviewed from the chart prior to the interview. Patients were also requested to report the regimen they have been using with the type of product prescribed. The extent of underutilization of ICS was calculated considering the appropriateness of ICS regimen (the dose and frequency of ICS) the patients have been using for given asthma category compared against recommendation of GINA guideline for the specific step of asthma management [1]. In addition, patients who were eligible for ICS but without prescription for ICS, patients who were prescribed ICS but not using then were counted under category of inadequate ICS use. Asthma and ICS knowledge was dichotomized into good and poor by computing sum of questionnaires assessing knowledge for each patient and taking median score as cut-off point. Similarly, attitude toward asthma and ICS were dichotomized into positive and negative attitude by computing sum of the questionnaires assessing attitude for each patient and taking the median score as cut-off point.

The data was entered into epi info version 7 and analyzed using Statistical Package for Social Science (SPSS) for windows version 20. Each variable was evaluated independently in a bivariate analysis and association was determined using cross tabulation and crude odds ratio (COR) with 95% CI. All variables associated with the underutilization of ICS at a probability level of less than or equal to 0.25 on the bivariate analysis were entered into a multivariate logistic regression analysis to control for confounders. The covariates tested includes; educational status, types of ICS products prescribed, monthly income, duration of asthma, comorbidity, severity of asthma, asthma knowledge and ICS knowledge. The final model was selected by using Wald criterion and Hosmer and Lemeshow test to determine variables that were independently associated with underutilization of ICS at a probability level of less than 0.05 and presented using adjusted odds ratio (AOR).

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