Multiple levels of influence affecting the utilisation of adult asthma
      services in the private sector in Khartoum
Creators: name: Thomson, Rachael
Publisher: name: Lancaster University
Year: 2019

description: 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.