Multiple levels of influence affecting the utilisation of adult asthma services in the private sector in Khartoum

Background Asthma is the third most common cause of hospital visits in Sudan and globally affects more than 300 million people (WHO, 2007) (IUATLD, 2011, 2018). Sudan has a pluralistic health care system with a strong and varied private sector and a three- tiered public health sector (federal, state and district). Most asthma patients in Sudan seek asthma care in hospital emergency rooms or in the private sector. The main constraints of the asthma services in the public sector are lack of resources, lack of medical doctors in certain areas, inconsistent drug supplies and an absence of community involvement in health affairs (Ebrahim et al., 2017). While there has been research examining the low availability of asthma services in the public sector in Sudan (El Sony et al., 2013), very little is known about which asthma services are available in the private sector. Objective The goal of this thesis was to use a mixed method approach to understand the utilisation of adult asthma services in the private sector in Khartoum. Design The research design was constructed using an explanatory sequential mixed method Social Ecological approach (Creswell, 2013). This approach was used to examine the influencing factors of asthma service utilisation in the private sector by considering the five nested, hierarchical levels: individual, familial/interpersonal, community, organisational, and policy/enabling environment. The quantitative research was conducted using a health facility survey of private hospitals, private chest clinics, and pharmacies, in order to describe the asthma services available. This was followed by qualitative research using in-depth interviews with asthma patients who use the private sector, to explore decision-making around facility use and asthma health care seeking behaviour in more detail. Findings The quantitative survey found low rates of spirometers and peak flow meters were available in private hospitals (28% and 33%, respectively). There was very little asthma-specific training for providers and little use of asthma treatment cards and registers. However, the qualitative interviews found that the quality of care in the private sector was viewed as better than in the public sector, with shorter waiting times and better hygiene levels. Patients sought frequent, short-term care at private facilities for acute attacks (predominately in hospital emergency rooms) rather than long-term management of their condition as outpatients. The severity of the disease and the major impact it had, particularly on younger adults’ lives, was striking. Stigma and misconceptions about the disease by the community was expressed strongly particularly by younger women and altered how they sought care and how they interacted with people in their social network and beyond. Conclusion The Social Ecological approach facilitated an in depth understanding of the barriers and enablers of effective care. Effective asthma case management requires input at all levels of service provision: inclusive health policy and government commitment, high quality service delivery, an uninterrupted affordable drug supply, community involvement in care and patient empowerment. Encouraging stakeholders across the different levels of influence to implement this holistic model of asthma case management across both the public and private sector has the potential to lead to a reduction in emergency room admissions, less severe asthma attacks, a reduction in asthma related stigma and less fear of social rejection and concern for the patients.