Family Practice Vol. 19, No. 5, 448-451
© Oxford University Press 2002
Outcomes of an intervention programme for treatment of asthma in a primary care clinic for Bedouins in southern Israel
a Department of Family Medicine and
d Division of Health in the Community, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel,
b Kuseife Clinic, Clalit Health Services, Southern Region and
c Southern Region Administration, Clalit Health Services.
Roni Peleg, MD, Department of Family Medicine, Ben-Gurion University, POB 653, Beer-Sheva, Israel, 84105; E-mail: pelegr{at}bgumail.bgu.ac.il
Peleg R, Gehtman P, Blancovich I, Aburabia R, Allush R, Hazut S and Shvartzman P. Outcomes of an intervention programme for treatment of asthma in a primary care clinic for Bedouins in southern Israel. Family Practice 2002; 19: 448–451.
Received 4 December 2001; Revised 9 April 2002; Accepted 13 May 2002.
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Abstract |
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Background. Asthma is one of the most common disorders affecting children and adults. There is a large variation in the theoretical and practical knowledge and skills of physicians, and patients often do not receive optimal treatment. Thus, asthma represents a great challenge to the primary health care system
Objective. Our aim was to evaluate an intervention programme for the optimization of treatment of asthma in a primary care clinic in the Muslim Bedouin sector in southern Israel.
Methods. Over a 3-month period, data were collected on the number of nebulizer treatments received by asthma patients in the clinic, referrals to the emergency room, hospitalizations and availability of electric nebulizer equipment or space chambers in the homes of children with asthma. Following this, an intervention programme was designed and implemented to improve treatment of asthma. At the end of the intervention 1 year later, the same data were again collected in the same season as the pre-intervention data.
Results. Of 3428 children registered in the clinic, 267 were diagnosed with asthma (7.8%). During the 3-month period before the intervention, 73 children had home inhalation equipment, 61 referrals to the emergency room were documented and six children were hospitalized for exacerbation or complications of the disease. Over this time period, 5.54 nebulizer treatments were conducted in the clinic per month per 100 children and adults. Following the intervention, the number of referrals to the emergency was reduced to six children, none of whom was hospitalized. The number of children with home nebulizers was doubled. The number of nebulizer treatments in the clinic dropped to 4.7 per month per 100, a reduction of 15%.
Conclusions. An intervention including self-management of asthma with an emphasis on the proper use of inhalers and medications, together with improved disease management at the clinic itself, led to a reduction in the episodes of asthma and its complications.
Keywords. Asthma, Bedouins, family medicine, paediatric care, quality of care.
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Introduction |
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Asthma is one of the most common disorders affecting children and adults. In children, prevalence rates are 5–10%.1 In the USA, asthma accounts for 23% of school absenteeism and is one of the major reasons for hospitalization of children.2 In the 1970s and 1980s, the rate of paediatric hospitalizations for asthma increased 2-fold and even more.3 Data indicating that the death rate from asthma increased 46% in the period from 1980 to 1989 are even more disturbing.4
Despite improvements over recent years in diagnosis and treatment, asthma-related morbidity and mortality also continue to rise in Israel.5 In 1994, 142 individuals died of asthma in Israel; of these, four were children. However, asthma continues to be under-diagnosed and under-treated. Thus, it represents a great challenge for the primary health care system, particularly in the Bedouin population with its unique cultural and living conditions.
The aim of the present study was to evaluate an intervention programme for treatment of asthma in a primary care clinic in the Muslim Bedouin sector in southern Israel.
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Methods |
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Setting
The study was conducted in the Kuseife Clinic, a rural Bedouin primary care clinic in Israel’s southern Negev region. The clinic provides primary health care services to ~8600 registered patients, of whom 53% are children up to the age of 14. The natural rate of population increase is 5.3% per year. The population is comprised of Bedouins of low socio-economic status, many of whom live in small houses made of cinder blocks, wooden or tin huts, or even tents. Many of the residents have no electricity in their homes. A large proportion of the population are on welfare or work at occasional odd jobs. Most have only a few years of formal education. This population is characterized by a poor compliance rate for treatment and follow-up among asthma patients. At times, they are unable, for economic reasons, to purchase the necessary equipment and/or medications. There is a low level of awareness of the health hazards of smoking, and the smoking rate in the population is high, although precise statistics are unavailable.
All clinic encounters are recorded in a computerized system.
Baseline data prior to implementation of the intervention programme
Over the course of 3 months from November 1999 to January 2000, a mean of 5.54 nebulizer inhalation treatments were conducted per month per 100 children and adults.
Of the 3428 children registered in the clinic, 267 (7.8%) were diagnosed with asthma. In this population, 9.89 nebulizer treatments were given per 100 children per month.
In the study period, there were 61 referrals to the emergency room for exacerbation of asthma, and six children were hospitalized. Seventy-three children (27%) had electric nebulizer equipment or space chambers for self-treatment at home.
Definition of the problem
The data presented above may indicate suboptimal treatment, which may be manifested by some or all of the following: inadequate drug therapy, impaired quality of life for the patient and his/her family, excessive need for treatment at the clinic, additional workload on the clinic staff, unnecessary clinic appointments, exposure to other diseases, dissatisfaction with treatment and long waiting times at the clinic.
The intervention programme
Over the course of 1 year starting from the conclusion of the collection of baseline data, an intervention programme was implemented. The intervention was based, primarily, on treatment of asthma as recommended in the clinical guidelines of the Clalit Health Services, which are similar to treatment guidelines published by other bodies. The intervention programme included:
- Updating of knowledge. Updated guidelines were presented to the entire clinic staff at staff meetings.
- Health education for the clinic population. Educational activities were focused on improved living conditions, cleanliness and hygiene.
- Use of medication. All clinic asthma patients were asked to bring their medications and equipment to the clinic and to demonstrate the technique they used to treat themselves. It was clear that most patients did not take medications in a timely manner, nor did they use the equipment properly. Many were not clear as to the purpose of treatment or how the equipment worked.
- Ongoing instruction by the clinic staff. At every visit to the clinic, asthma patients were counselled by the staff as to the proper use of medication and equipment.
- Provision of space chambers. Space chambers were solicited from a drug company and given, free of charge, to patients who had applied to the Department of Welfare for help in acquiring this essential piece of equipment.
- Avoidance of allergens. Patients were instructed to avoid allergens such as smoke from their parents’ cigarettes or campfires, and animals.
- Health fair for patients and families. Patients and their families received written and personal invitations to a health fair on the subject of asthma. At the fair, the patients were received at four stations: (a) general information on asthma; (b) a 20 min videotape on allergens and asthma; (c) demonstration and practice of the use of nebulizers and space chambers using simulation equipment; and (d) an individual review of medications.
The intervention activities were conducted in Arabic. Over 100 asthma patients, including 80 children and parents, attended the health fair. After the programme ended, data were again collected over the corresponding period of 3 months from November 2000 to January 2001.
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Results |
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Results following the intervention programme
The mean number of nebulizer treatments per 100 asthma patients in the clinic per month dropped to 4.7, a reduction of 15%. The number of referrals to the emergency room dropped to six among the 276 children with asthma, and no children were hospitalized. The mean number of nebulizer treatments among 100 children per month dropped to 6.9, a reduction of 30.2%. The number of children with an electric nebulizer or space chamber at home increased to 150, an increase of 199%. A comparison of data prior to and following the intervention programme is presented in Table 1
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Discussion |
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The interval of a year in timing of data collection, before and after the intervention programme, was chosen to ensure full implementation of the programme and to negate seasonal factors that might independently affect the results of the data analysis.
Although some guidelines on asthma have recommended self-management,6 conflicting results exist regarding its efficacy.7,8 Some studies either have been uncontrolled or have relied on retrospective data. Potentially preventable factors are common in cases of death from asthma, and 73% of admissions to hospitals for acute asthma could be avoided with proper prior medical care.9 Self-management reduces episodes of asthma and improves quality of life.10
In our intervention programme, we incorporated self-management with an emphasis on proper use of inhalers and medications, together with improved disease management at the clinic itself. The significant increase in the use of home equipment, the drastic reduction in the number of referrals to the emergency room and the total absence of hospitalizations for asthma demonstrate the positive effect of the programme.
The results relate to a study that was conducted under unique conditions in terms of living conditions, such as lack of electricity in some homes, exposure to dust, mud and campfire smoke, as well as cultural difficulties in adhering to paediatric treatment protocols.
It is possible that there were climatic differences between the two winters of the study and that the risk of disease exacerbation was not identical, thus leading to a bias in the study results, but we are not able to quantify this potential confounding factor.
As a result of the intervention programme, there was an adjusted reduction of 15% in the number of nebulizer treatments for the entire clinic population and of 30.2% in the paediatric units that were analysed separately. This indicates that the reduction in the number of nebulizer treatments took place primarily among children, while the situation remained basically static among adult patients. The results indicate that an intervention programme, such as the present one, can lead to a reduction in asthma morbidity, and an improvement in quality of life for the patients and their families, as well as a reduction in expenses. In addition to the quantified results, the clinic staff reported an improvement in the quality of daily work in the clinic with regard to identification and treatment of asthma-related problems. The staff cited an improvement in their relationships with patients and families and an improvement in the level of confidence of the patients and families in the staff. Ongoing monitoring of self-management will provide data as to the long-term effectiveness of the programme.
There are differences throughout the world in terms of provision of health care services and culture-based attitudes to health care. Although we assume that our results are fairly representative of other areas inhabited by Bedouin residents in Israel, and perhaps the Palestinian Authority, we cannot be sure of their generalizability to other countries and health care systems. Nevertheless, we hope that our experience can help others in their attempts to improve the quality of management of asthma in primary care in other underprivileged populations.
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Acknowledgments |
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We would like to express our thanks to the Teva Pharmaceutical Co. for its aid in conducting the intervention programme including provision of equipment, instruments, lecturers and help with the health fair. We would like to express our thanks to Professor Asher Tal for his professional counselling.
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References |
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1 Starfield B, Katz H, Gabriel A et al. Morbidity in childhood: a longitudinal view. N Engl J Med 1984; 310: 824–829.[Abstract]
2 National Center for Health Statistics. The National Ambulatory Care Survey, United States 1979. Summary Ser. 13, No. 66. Hyattsville (MD): Department of Health and Human Services, 1982.
3 Halfon N, Newacheck PW. Trends in hospitalization for acute childhood asthma 1970–84. Am J Pub Health 1986; 76: 1308–1311.
4 MMWR. Asthma-United States, 1980–1990. 1992: 41: 733–735.
5 Israel Center for Disease Control. The State of Health in Israel. Sheba Medical Center, Tel-Hashomer, Israel: Israel Ministry of Health, 1997: 131–138.
6 National Heart, Lung and Blood Institute. National Institutes of Health International Consensus Report on Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung and Blood Institute, NIH, 1997.
7 Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms-only self management plan for control of asthma in general practice. Br Med J 1990; 301: 1355–1359.
8 Grampian Asthma Study of Integrated Care (GRASSIC). Effectiveness of routine self monitoring of peak flow in patients with asthma. Br Med J 1994; 308: 564–567.
9 Johnson AJ, Nunn AJ, Somnet AA, Stableforth DE, Stewart CJ. Circumstances of death from asthma. Br Med J 1984; 288: 1870–1875.
10 Lahdensuo A, Haahtela T, Herrela J et al. Randomized comparison of guided self management and traditional treatment of asthma over one year. Br Med J 1996; 312: 748–752.
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