Applying an ecological framework to examine the multiple levels of influence affecting the utilisation of private sector adult asthma services in Khartoum, Sudan: a mixed methods study

Abstract

Background: Asthma is the third most common cause of hospital visits in Sudan. Sudan has a pluralistic health care system, with a strong and varied private sector. While research examining public sector asthma services exists, very little is known about which asthma services are available in the private sector. Methods: An explanatory sequential mixed-method social ecological approach was used to examine influencing factors of asthma service utilisation in the private sector, considering five levels: policy, organisational, community, familial, individual environment. Quantitative research involved surveying private healthcare facilities to describe asthma services. Qualitative research involved in-depth interviews with asthma patients to explore facility decision-making. Nine private chest clinics, 44 pharmacies, and 21 private hospitals offering asthma services in Khartoum were studied - 46 female and 28 male health providers were surveyed; 7 male and 7 female asthma patients were interviewed. Results: At the health policy level, there is no current asthma management policy for the private sector. At the organisational and health systems level, the survey found low rates of diagnostic equipment available, little asthma-specific training, and little use of asthma treatment cards, guidelines, and registers. At the community level, high levels of stigma from the community were felt by most of the patients interviewed. At the familial level, asthma was often viewed as a hereditary condition, and, as a long-term condition, there were worries about marriage potential and impact on jobs/future activities. At the individual level, patients sought frequent, short-term care at private facilities for acute attacks. The severity of the disease and the major impact it had, particularly on younger adults’, was striking. Conclusions: Applying an ecological framework to examine asthma care management enables review of all levels of service provision: inclusive health policy, government commitment, high quality service delivery, uninterrupted affordable drug supply, community involvement, and patient empowerment.