All eligible healthcare workers agreed to participate in the study, and only one patient participant who was approached declined. A total of 20 patients (12 females) and 15 healthcare providers (five nurses, five pharmacists and five doctors, 10 of which were male) were interviewed (Table 1).
All but three patients were recruited from Kanifing General Hospital and Edward Francis Small Teaching Hospital Bakau Centre (formally Ndemban Clinic), and the final three patients were recruited from the Medical Research Council Gambia Clinic at LSHTM in The Gambia. Health professionals were recruited from the two government sector healthcare facilities, six from Kanifing General Hospital and nine from Edward Francis Small Teaching Hospital Bakau Centre (formally Ndemban Clinic).
Patients and providers, while positively recognising the benefits of inhaler use for asthma, expressed concern about the lack of access to inhaled medicines in The Gambian health system and noted this was a major challenge to asthma care. Both patients and providers had positive perceptions of inhaler use for asthma despite affordability and availability issues, and patient perceived harms from inhaler use. Patient experiences of inhaler use overwhelmingly focused on the use of inhaled SABA, as they had little or no experience with the use of inhaled corticosteroids for the treatment of asthma. The limited supply and lack of inhaled corticosteriod use meant few patients experienced the benefits of preventative treatment. Continued use of cheap oral SABA reinforced perceptions of asthma as a recurrent acute illness rather than a chronic condition that is often life-long. The requirement for ongoing asthma treatment and the ability to avoid acute attacks that lead to admissions was notably absent. Table 2 lists the themes and subthemes identified.
Poor availability and affordability affect prescribing and use of inhaled medicines
Patients repeatedly echoed experiences of being unable to obtain inhaled medications both in the public sector and in private sector pharmacies:
“[…] let’s be frank to each other, public hospitals don’t have medications. When you go there you wouldn’t have medications because none of them have medications […]” SU08
“[…]You know not everyone have the money to buy inhalers so if they give them the salbutamol pills they will take it and will not buy the inhaler. […]” SU17
What was very evident was that in contrast to the difficulties accessing inhalers, there was relatively easy access to SABA tablets, and these were often obtained from the public sector hospital:
“[…] at the hospital they will prescribe salbutamol for me take one tablet three times a day […]” SU05
These findings from patient interviews were mirrored in health professional interviews, with many reflecting on the lack of availability of inhaled medicines, even if prescribed:
“[…] all that I can say is they [inhaled medicines] are not available; for most they are not available.” HP03
“[…] as I told you in the government sector, and you don’t have much in the supply chain with inhale medicines.” HP10
There was a sense of futility and passive acceptance among healthcare workers, and they noted that their general prescribing behaviours were influenced by the availability of medicines. In many instances, practitioners were driven towards the prescribing of SABA tablets due to a lack of access to inhalers in the public sector:
“We, like I said, we have the oral, oral medicines in our health system. So basically, I desperately use the oral medications instead of inhaled medicines.” HP05
“For here, what we normally prescribe more, let’s say maybe 80% or more, is salbutamol tablets that that I’ve seen more.” HP14
Perceived harms of inhaled medicines
Patients and practitioners both described similar strongly held beliefs that they had encountered and which were said to be widely held by community members regarding the use of inhaled medicines.
“But when my husband asked me what did they give you, so I showed him, and he asked me not use the inhaler because I don’t have breathlessness frequently and if you get used to it, it might be a problem.” SU20
The beliefs encountered reflected concerns about dependence and worsening of asthma symptoms due to treatment, combined with, in some instances, the fear of death if inhaled medications were used and subsequently became unavailable. These beliefs were said to be often expressed by those within patients’ social networks. These harms were felt to be widespread:
“….like if I am addicted to and if I don’t have it, I can die… but some of the comments I receive from people, people are afraid of addictions, getting addicted to it and not getting it at the time of need so that is a concern people have. They are afraid of getting addicted to it.” SU16
Health professionals also reported this belief among their patients, and they noted that similar ideas and notions appeared to be strongly held and pervasive within Gambian society
“So sometimes they have this notion that maybe I am going to die because I must use the inhaler. Someone told me that if you stop using inhaler you will die.” HP01
“….most patient will not use because they think it makes you glue to it and because you glue to it you don’t recovery and you tend to have it a habit, that’s one misconception of it.” HP06
However, some patients directly challenged the circulating perceived harms based on their personal experiences of use of inhaled medicines.
“They said if one use it the person don’t recover from the illness but that doesn’t discourage me because each and every person know how one feels when sick. If the inhaler is helpful, the one using it knows about it. So those mere words don’t discourage me and there is someone with asthma who gave me his inhalers because he don’t use it.” SU12
“Many people do tell me not to get so used to the inhaler but I am still using it because it makes me feel relief.” SU13
Positive perceptions of asthma inhalers over tablets
Despite the lack of access to inhaled medicines and persistent negative lay beliefs said to be circulating in the community, patients and practitioners had positive perceptions of inhaled medicines for the treatment of asthma. This was apparent from the descriptions patients made by directly comparing tablets and inhalers:
“…..the inhaler [is] quicker to feel relief than the pills.” SU02
“The inhaler [is] the [more] quick reliever than the tablets because if I take the tablets I do feel relief but it takes time.” SU05
“….when you have attack and have the inhaler with you, you just use it and feel relief…” SU18
All healthcare workers interviewed expressed positive attitudes towards inhaler use and recognised their value.
“It (inhaler) works much better than oral. Because they are giving at a point of action where they need to act” HP06
Healthcare workers did describe a reluctance around the prescribing of inhalers, as they are harder to source and pay for in addition to circulating beliefs around their addictive potential and risk of death.
“but if they are not available patients have to buy it from outside which is an obstacle because some of them cannot afford it” HP07
Asthma as an acute and not chronic condition leading to recurrent hospitalisation
There was a relative absence of the role of prevention in asthma, and the dominant discourse was that this was an acute condition and, because of this, a view that hospital management was the most appropriate way to treat asthma. Only two healthcare workers reflected on their experiences of the use of inhaled corticosteroid, with one noting how a lack of availability reinforces patients’ limited awareness of the need for it:
“Once they [patients] start these, these daily, like inhaled corticosteroid, the difference [is] remarkable…………so basically, the mainstay of treatment is inhaled corticosteroids. For many years, it’s not been available, so [patients], they’re not aware of it.” HP04
Perhaps not surprisingly given the lack of access, the use of inhaled corticosteroids was a notable omission from patients’ narratives and those of most healthcare workers. Asthma was overwhelmingly described by patients as an acute illness of repeated attacks, and there was no reference in patient narratives to it being a long-term chronic condition. Moreover, the acute perception of asthma led to the dominance of the hospital being the most appropriate health setting within which to manage asthma:
“I have been going to different hospital whenever I have attack. I went to many hospital because I have asthma since I was a child.” SU01
“….and when I have attack I will go to Kanifing General Hospital and they will nebulize me and go home. It will take a month or three weeks it comes back again and go back to the hospital again.” SU05
“Sometimes will get back home and within 30 to 40 minutes will go back again to the hospital so my condition was not improving…” SU17
This was also reflected in the descriptions by healthcare workers of their experiences of treating asthma patients in the health system:
“Like I said, like if you if you spend a week at our emergency department, you see the same faces come back forth.” HP04
“but when it comes to dealing with these patients, we manage them all the time—they keep going and coming [back].” HP09
The limited supply and lack of inhaled corticosteriod use means few patients experience the benefits of preventative treatment. This, coupled with the continued use of cheap oral SABA, reinforces the perception of asthma as a recurrent acute illness.