Asthma Control in Oman

Abstract

Objectives:

The Asthma Insights and Reality (AIR) study in the Gulf and Near East (one of a worldwide series of surveys conducted in adults and children to assess asthma control) was conducted in Oman to assess how closely asthma control meets international guidelines recommendations.

Methods:

From January 2007 to March 2008, asthmatics receiving treatment or currently suffering from asthma symptoms were interviewed among nationals randomly surveyed from the most populated urban areas in Oman (Muscat, Sohar and Nizwa). The standard AIR questionnaire was used to assess symptom severity, health care utilisation, limitation of activity and medication use.

Results:

From 201 asthmatic participants, 21% were under 16 years and 43% were female. Tobacco use was low in our asthmatics. Disparity in asthma perception was wide in Oman; while 57% of asthmatics perceived their asthma as well or completely controlled, actually 54% had poorly or not well controlled asthma. All recommendations for asthma control by the Global Initiative for Asthma were largely unmet, especially in child asthmatics, with 44% reporting night awakenings due to asthma during the previous 4 weeks and 47% exercise-induced asthma in the previous 12 months. Overall, 32.6% of children and 34.8% of adults reported absence due to asthma from school/work during the previous year. Use of preventive inhaled corticosteroids was only 5.0%, one of the lowest even within the AIR Gulf and Near East study, producing an unacceptable ratio ICS/SABA (inhaled corticosteroid/short acting beta-agonist) of 0.054 in Omani asthmatics.

Conclusion:

Asthma control in Oman falls far below the goals of current international guidelines therefore corrective strategies are needed.

Advances in Knowledge

1. Current international asthma initiatives, both for children and adults, recommend to measure the asthma burden worldwide. However, to date there were few studies conducted in the Gulf and none in Oman focused on measuring asthma control and asthma severity.

2. The current use of preventive medications in Omani asthmatic children and adults appear to be one of the lowest in the Gulf region, and even worldwide.

Application to Patient Care

1. Doctors in Oman should be aware of the burden of asthma.

2. Educational and corrective strategies should be implemented in Oman to improve individual and population asthma management.

The Global Initiative for Asthma (GINA) guidelines, which were introduced in 1995,1 followed by many other local guidelines, all aimed at improving asthma patient care and ensuring better long-term control of the disease. Control was the cornerstone of the latest GINA update in 2006.2 Studies have shown that total asthma control is achievable in most patients.3 There exists, however, a wide gap between the goals of treatment as set out in the guidelines and actual real-life clinical practice outcomes. Recently, several Asthma Insights and Reality (AIR) surveys were conducted in various countries around the world, including the USA, Canada, the Asia-Pacific region, Western and Central-Eastern Europe, Japan, Latin America, Saudi Arabia, and most recently in the Gulf and the Near East. They all aimed to determine variations in asthma severity and control, both from the patient perspective and objectively, compared to what is recommended by the guidelines. Consistently, these surveys demonstrated a poor level of asthma control in all the above mentioned countries and regions, with local variations specific to each country.

Oman is in the Middle East at the northern edge of the Gulf with a population of about 2.6 million inhabitants. There is a paucity of statistics about asthma prevalence and asthma burden in Oman. By using the International Study of Asthma and Allergies in Childhood (ISAAC) methodology 2003, Al-Riyami et al. reported prevalence rates of diagnosed asthma in Oman of 20.7% in 13–14 year-olds, whereas in younger children (6–7 years) it was 10.5%.4

The prevalence of severe asthma (sleep-disturbing wheeze and speech-limiting wheeze) and frequent symptoms in Omani schoolchildren (age between 6–7 years), compared with other ISAAC participating countries in the East Mediterranean region, was higher than in any other country in the study. Similarly, the prevalence of sleep-disturbing wheeze among Omani children was nearly four times that of Iran and almost double that of Malta.4 We also previously reported that more than 50% of our adult asthmatic patients felt that their asthma had a negative impact in their work, school or home duties.5 Nocturnal symptoms were common in our studied patients, only 44% reported having had no night-symptoms in the previous 4 weeks, while the rest felt their asthma often disturbed their sleep. This ranged from 4% reporting two to three wakeups per night to 28% reporting one to two wake-ups due to asthma in the last 4 weeks.5

The GINA guidelines have been developed to promote standardised methods of diagnosis and treatment of asthma that now are generally accepted worldwide. Research published since the release of the GINA guidelines indicates that in many countries patients with asthma are unequally treated and that adherence to asthma treatment guidelines is poor.6,7

All AIR studies aimed to assess the discrepancy between perceived symptoms and subjective assessments versus objective control and the burden of asthma in order to determine the implementation status of the goals and management recommendations advocated by GINA. They also have helped to shed light on the perceptions, knowledge and attitudes related to asthma at the local level in order to assist in future national policy development. Oman was one of the Gulf and Near East countries included in the AIR Gulf and Near East (AIRGNE) study, together with Jordan, Kuwait, Lebanon, and the UAE. The summary results have been published elsewhere,8 but the specific Omani data results warrant a closer look and are presented in this paper.

Methods

The AIRGNE survey was conducted between January 2007 and March 2008. The most populated urban areas in Oman were surveyed in AIRGNE, namely the capital area, Muscat/Seeb/Mutrah, with 60% of the sample; Sohar, a port city on the northern coast of Oman with 25%, and Nizwa, a city 120km south west of Muscat in the Dakhiliyah region with 15%. The sampling was structured by gender and age within each city or urban area.

Asthma patients were identified by systematically screening a sample of households for persons who had been diagnosed with asthma. A sampling plan was designed to provide a nationally representative sample of households that could be screened to identify a community sample of current asthma sufferers for Oman. A geographically stratified sample of households, proportionate to the population, was drawn within the three designated areas. The survey design required a sample of 200 asthma patients. In each household, an adult was asked whether a physician had ever diagnosed any member of the household as having asthma. If the answer was “yes”, the interviewer asked whether any of these individuals were currently taking medication for their asthma, or had suffered an asthma attack or experienced asthma symptoms in the past year. The number of persons in the household, as well as the number who had been diagnosed with asthma and met the survey criteria for current asthma, were collected to provide estimates of comparative prevalence. If more than one household member qualified as a current asthma patient, the interviewer randomly selected one as the designated respondent. Only one respondent was interviewed per household because multiple interviews in the same household would have created a bias. If the selected respondent was 16 years of age or older, the interview was conducted with the patient; if he/she was 15 years or younger, the interview was conducted with the parent or guardian most knowledgeable about the child’s asthma condition and treatment.

The study was approved by the Ethics Committee of the Ministry of Health, Oman. This study was non-interventional and anonymous, and no individual identifiers were obtained or stored. Following the advice of the coordinating team in Europe (JB Soriano) it was considered that the verbal authorisation from individual asthmatics (or his/her parent) would be sufficient consent.

The core questionnaire was that used in previous AIR studies in Europe and elsewhere,8 which was based on the original ATS (American Thoracic Society) questionnaire.9 The questionnaire was translated into Arabic and then translated back again; any discrepancies or inconsistencies discovered by this process were solved by consensus. In addition, the following items were included: self-completion of the asthma control test (ACT) questionnaire,10 various questions modified to reflect the local conditions and characteristics of asthma in Oman and some additional questions to reflect the latest GINA guidelines. It was administered with an English-Arabic side-by-side layout,8 available online from the International Journal of Tuberculosis and Lung Disease (IJTLD) website.10

As per standard quality control procedures, all materials were piloted. There was also a personal briefing of all interviewers in each region, and each interviewer conducted two pilot interviews and reviewed the completed questionnaires with a supervisor before starting fieldwork. Completed questionnaires were checked locally and again centrally, and a random double check of interviews in all regions was conducted by telephone. Finally, all data were included in a database after independent double typing.

The frequency and severity of daytime and nighttime symptoms, exercise-induced symptoms and severe episodes, and total symptom frequency, were used to develop a symptom severity index similar to the GINA asthma severity scale.11 In addition, events such as hospitalisations and emergency care utilisation were documented, as well as the impact of days of school/work lost due to asthma. Patient demographic and asthma severity characteristics were compared using chi-squared analysis to identify factors that might account for differences in asthma management across the country, or analysis of variance for quantitative variables whenever required. Statistical comparisons within the country versus the published international AIR estimates were explored. All statistical tests were two-sided and comparisons with <5% probability of error were considered statistically significant.

Results

A total of 201 valid interviews with Omani asthmatics in the three participating cities were completed, of whom 115 (57%) were male. The age distribution was very young, with 21% of the sample being 5–15 years old and 33% 16–29 years old. Most participants had only completed primary (38%) or secondary (30%) education. Reported income was lower than $1,000 per year in 75% of surveyed participants, while reported smoking in adults was minimal [Table 1].

Table 1:

Demographic characteristics of asthma patients. Values correspond to numbers (percentages) of patients in the corresponding category except for age of adults and children at inclusion and age at diagnosis which are represented as means ± standard deviation (13.5 ± 6.7)

Parameter	Population N = 201
Interval age distribution
5–15 years	43 (21%)
16–29 years	67 (33%)
30–49 years	71 (35%)
> 50 years	20 (10%)
Age at diagnosis, mean;	13.5
Gender
M	115 (57%)
F	86 (43%)
Level of education
Primary	77 (38%)
Secondary	62 (30%)
University	62 (30%)
Income
<1000 $	152 (75%)
1000–2000 $	36 (18%)
>2000 $	13 (6%)
Region
Muscat	121 (60%)
Sohar	50 (25%)
Nizwa	30 (15%)
Smoking habits in adults
Never smoked	173 (96%)
Former smokers	7 (3%)

A total of 90 (57%) of adult asthmatic responders (n = 158) perceived their asthma as “well” or “completely” controlled. The actual figures show, on the contrary, that 54% of adult responders had “poorly” or “not well” controlled asthma. (P <0.05).

A total of 71% of participating Omani asthmatics reported day-symptoms during the previous 4 weeks. Similarly, 44% reported night awakenings due to asthma during the previous 4 weeks and 47% exercise-induced asthma in the previous 12 months, both were particularly frequent in child asthmatics [Table 3]. Exacerbations and use of health services were equally high, and limitations of daily activities due to asthma were widespread both in children and adult asthmatics. One in three asthmatics had never had their lung function tested and few owned a peak flow meter.

Table 3:

The Global Initiative for Asthma (GINA) recommendations for asthma control and the Asthma Insights and Reality in Oman (AIRO) results

GINA definition for control of asthma	AIRO findings	Adults (%)	Children (%)	All (%)
Minimal (ideally no) chronic symptoms, including nocturnal symptoms	Asthma symptoms
	During day (past 4 weeks)	73	81	71
	Night wakening (past 4 weeks)	45	60	44
	Exercise-induced asthma (past 12 months)	51	60	47
Minimal exacerbation	Sudden severe episodes in past 12 months	95	84	93
No emergency visit for asthma	Hospitalisation (past 12 months)	35	42	30
	Emergency department visit (past 12 months)	18	36	21
Minimal need for short-acting ß2-agonists	Current use of quick-relief bronchodilators	-	-	85
No limitation on activities, including exercise	Asthma restricts
	Sports and recreation	38	77	46
	Normal physical Activity	35	70	43
		18	14	17
	Choice of jobs/careers	32	42	34
	Social activities	22	56	29
	Sleeping	21	49	27
	Lifestyle	20	49	26
	Household chores
Normal or near-normal lung function (PEF variability 20%)	Never had a lung-function test	42	19	35
	Owns a peak flow meter	17	35	25

Legend: PEF = peak expiratory flow.

A total of 32.6% of children reported school absence due to asthma during the previous year, with a mean standard deviation (SD) of 6.1 (8.5) days. In adults 34.8% reported work absence due to asthma during the past year, with a mean SD of 9.9 (9.8) days [Table 4]. Use of health services was similarly high compared to other AIRGNE participating countries, with 30% of hospitalisations and 58% of emergency (unscheduled) medical visits.

Table 4:

Evaluation of asthma burden in the past year in Oman by comparison to Asthma Insights and Reality in the Gulf and Near East (AIRGNE) study results

	Oman (N = 201)	AIRGNE (N= 1,000)	P value
Asthma burden in the past year
School absence in children, %	32.6	51.7	<0.05
Mean number of days (SD)	6.1 (8.5)	7.9 (9.6)
Work absence in adults, %	34.8	29.7	0.420
Mean number of days (SD)	9.9 (9.8)	7.3 (8.1)
Use of health services in the past year
Hospitalisation, %	30.0	22.5	0.723
Emergency medical visit, %	58.0	51.5	0.571

Legend: SD= standard deviation.

Finally, current use of preventive inhaled corticosteroids was 5.0%, one of the lowest even within the AIRGNE study, with a mean of 14.6%. Most (92%) patients relied rather upon quick relief medications, producing an unacceptable ratio ICS/SABA (inhaled corticosteroid/short acting beta-agonist) of 0.054 [Table 5]. As mentioned above, there was a low prevalence of both ownership of a peak flow meter (25.4%) and ever having had a lung function test (35.0%) in the Omani asthmatics in this study.

Table 5:

Current use of preventive inhaled corticosteroids and quick relief medications, and evaluation of lung function in Oman by comparison to Asthma Insights and Reality in the Gulf and Near East (AIRGNE) study results

	Oman (N = 201)	AIRGNE (N= 1,000)	P value*
Current use of medication (previous 4 weeks)
Use of ICS, %	5.0	14.6	<0.05
Use of quick relief, %	92.0	55.5	<0.05
Ratio ICS/SABA	0.054	0.26	<0.05
Lung function
Own a peak flow meter, %	25.4	17.1	<0.05
Ever had a lung function test, %	35.0	32.7	0.746

Legend: ICS= inhaled corticosteroids; SABA= short acting beta-agonist.

Discussion

AIRGNE-Oman was the first survey in the country to assess objectively the level of control and severity of asthma. It demonstrated that asthma management was poor in 2007–2008 compared to recommendations in published guidelines. As in all previously published international AIR studies, asthma is poorly managed in Oman with the performance far below the recommended goals of any guidelines. This was obvious when the actual GINA recommendations of control were compared to the AIRGNE-Oman findings [Table 2], clearly showing that guideline-based control was not achieved at the time in of our study.

Table 2:

Comparison between objective and subjective evaluation of asthma control

	Subjective asthma control§	Objective asthma control*	P value
Poorly and not well controlled	68 (43%)	86 (54%)	<0.05
Well/completely controlled	90 (57%)	72 (46%)

Note:

§ = Adult responders only (n=158);

*= objective evaluation of asthma control relies on the asthma control test (ACT). An ACT of 5 to 19 corresponds to a poorly and or not well controlled asthma, and an ACT of 20 to 25 corresponds to a well controlled asthma for adult responders only (n=158).

In the European and Asia Pacific AIR studies approximately half of the adult patients reported daytime symptoms. The overall figure in the AIRGNE study was 68%, and it was equally high in Oman (71%) in the present study. These results are close to the findings of Rawas et al. as they found nearly 60% of all current wheezers reported at least one of the symptoms indicating severe or uncontrolled asthma.¹⁴ Night awakenings were also frequent in the AIRGNE-Oman study (44%), and this finding is compatible with the study of Al-Riyami et al.4 where the prevalence of sleep-disturbing wheeze in Oman was nearly four times that of Iran (3.5% versus 0.9%) and more than double that of Malta (3.5% versus 1.5%). It was even higher than that of Australia (3.5% versus 2.8%), a country with the highest prevalence rate of wheeze among all ISAAC participating countries, being more than three times that of Oman.

The frequency of hospitalisation in Oman in the previous twelve months was also high, reaching 30%. Emergency department visits were high in Oman, as in other AIRGNE countries, the figures being 58% and 51% respectively. These figures were much higher than those in the study conducted by Al Rawas et al.12 Of the asthmatic patients in his study, who were attending asthma specialty clinics, only 31.9% had visited the emergency department and 15.0% patients had been hospitalised at least once during the previous year.

On the other hand, school absence in children was significantly less frequent in Oman than in other AIRGNE countries (32.6% versus 51%; P <0.05, Chi 2 p statistic when compared to AIRGNE results.) Another positive finding among adult asthmatics in AIRGNE-Oman study was the very low prevalence of smoking, with only 3% of respondents reporting either a current or previous smoking habit. This is probably one of the lowest figures recorded worldwide,13 and indeed an achievement to be sustained in the future.

The current use of asthma medications in Oman is disappointing. According to the findings in this study, only 5% of asthmatics were using inhaled corticosteroids compared to 14.6% in other AIRGNE countries (P <0.05). On the other hand, the use of rescue medication was strikingly high, with 92% of asthma patients reporting daily use of them compared to 55.5% in other AIRGNE countries. Interestingly, these findings totally differ from Al Rawas et al. where 92% of asthma patients attending asthma specialty clinics used inhaled corticosteroids.12 The discrepancy is likely due to the fact that patients in asthma specialty clinics are seen by chest specialists who are aware that steroid inhalers are the cornerstone of asthma treatment; it is also possibly due to the fact that these patients have more severe asthma.

Most patients overestimated their level of control and underestimated their disease severity, as there was a disparity in the patient subjective versus objective asthma severity perception. While 90 (57%) of asthmatics perceived their asthma as well or completely controlled, actually 54% had poorly or not well controlled asthma as objectively identified by an ACT score of 5 to 19 (P <0.05). The frequency of lung function tests was generally low in Oman, being at similar levels to other AIRGNE countries, as only 35% reported their lungs ever tested, and only 25% owned a peak flow meter.

Overall, when comparing the Omani results with the AIRGNE average, the management of asthma in Oman was worse in terms of reporting a higher use of rescue medications and very low uses of inhaled corticosteroids, as well as unacceptably frequent visits to emergency departments.

There are some potential limitations of this survey. First, sampling was not performed according to Random Digit Dialing (RDD) as in most other AIR surveys. In countries where telephone ownership levels approach 100% and comprehensive databases are available, RDD can approximate a representative random sample of the population. However, RDD was not considered appropriate in Oman, and overall in the GNE, because of the low penetration of telephone coverage.

Second, there are problems associated with the term asthma in our country, therefore many doctors avoid using this term, and use instead the term allergy, with an intention to making it milder and more acceptable to patients themselves or to their parents. Perhaps third, the sample size of 201, while being considerable enough, gives some subgroup analyses (by young children or in severe asthma) reduced statistical power. Therefore, more studies are needed to monitor all trends and assess current interventions.

Conclusion

The AIR study in Oman highlights the gap between the recommended long-term asthma management guidelines and the reality in Oman. International guidelines recommend treating inflammation and not symptoms, but the trend of poor inhaled corticosteroid utilisation among Omani patients with persistent asthma suggests undertreatment. This implies an immediate need to improve communication and awareness among patients and physicians, specifically to reinforce the use of anti-inflammatory medications. Underestimation of the severity of asthma and overestimation of asthma control by both patients and physicians are important factors contributing to poor asthma control.