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Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study
Chris Griffiths a Department of General Practice and Primary Care,
St Bartholomew's and the Royal London School of Medicine and
Dentistry, Queen Mary's School of Medicine and Dentistry, London E1
4NS, b Department of Human
Science and Medical Ethics, Royal London Hospital, London E1 2AD, c Newham General Hospital, London E13 8RU Correspondence to: C
Griffiths c.j.griffiths{at}mds.qmw.ac.uk
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Abstract |
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 Top
 Abstract
 Introduction
Participants and methods
Results
Discussion
Appendix
References
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Objective:
To explore reasons for increased risk of
hospital admission among south Asian patients with asthma.
Design:
Qualitative interview study using modified critical incident technique and framework analysis.
Setting:
Newham, east London, a deprived area with a
large mixed south Asian population.
Participants:
58 south Asian and white adults with
asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.
Main outcome measures:
Patients' and health
professionals' views on influences on admission, events leading to
admission, general practices' organisation and asthma strategies,
doctor-patient relationship, and cultural attitudes to asthma.
Results:
South Asian and white patients admitted to hospital coped differently with asthma. South Asians described less
confidence in controlling their asthma, were unfamiliar with the
concept of preventive medication, and often expressed less confidence
in their general practitioner. South Asians managed asthma
exacerbations with family advocacy, without systematic changes in
prophylaxis, and without systemic corticosteroids. Patients describing
difficulty accessing primary care during asthma exacerbations were
registered with practices with weak strategies for asthma care and were
often south Asian. Patients with easy access described care suggesting
partnerships with their general practitioner, had better confidence to
control asthma, and were registered with practices with well developed
asthma strategies that included policies for avoiding hospital admission.
Conclusions:
The different ways of coping with asthma
exacerbations and accessing care may partly explain the increased risk
of hospital admission in south Asian patients. Interventions that
increase confidence to control asthma, confidence in the general
practitioner, understanding of preventive treatment, and use of
systemic corticosteroids in exacerbations may reduce hospital
admissions. Development of more sophisticated asthma strategies by
practices with better access and partnerships with patients may also
achieve this.
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What is already known on this topic
What this study adds
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Introduction |
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Top
Abstract
Introduction
Participants and methods
Results
Discussion
Appendix
References
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Black and south Asian people are at increased risk of hospital admission with asthma.1-7 Analysing 15 921 admissions, Gilthorpe reported higher age standardised admission rates for black and south Asian patients compared with white patients, with excess risk only partially attributable to socioeconomic status.5 In Birmingham and Blackburn respectively, Ayers and Ormerod found that risk of admission for south Asian adults was more than double that for white adults. 2 4 Despite these findings, no consistent differences in severity or prevalence of asthma, prescribed drugs, or asthma education have been described. 1 4 8 In one study south Asian patients were less likely to report adherence to their drug regimen or self management behaviour.1 Interventions to reduce admission rates in black and Asian groups have met with variable success.9-11
Differences in hospital admission rates for asthma between ethnic
groups might be because of differences in beliefs or behaviour during
exacerbations or in access to or delivery of care. Our aim was to
explore these factors in south Asian and white adults admitted to
hospital with asthma.
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Participants and methods |
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Top
Abstract
Introduction
Participants and methods
Results
Discussion
Appendix
References
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The study setting was Newham, east London, a highly deprived area with a large (30%) mixed south Asian population (Indian, Pakistani, and Bangladeshi).12 The local research ethics committee approved the study.
Participants
Patients admitted with asthma
We recruited 49 south Asian and white adults admitted with acute asthma to Newham
General Hospital (see box 1 for details). Recruitment was, as far as
possible, consecutive (an intensity sample).13 We identified patients on hospital wards, verified diagnoses in records, and asked patients to name their usual general practitioner. As recruitment proceeded, we reviewed the sample to ensure maximum diversity of experience in terms of age, ethnicity, religion, duration
and management of asthma attack, and route of hospital admission. The
diversity of south Asian groups in Newham was reflected in the sample.
Since the patients
admitted to hospital might be atypical in terms of their asthma
management, we compared their experiences with those of a limited
number of patients with severe asthma (British Thoracic Society (BTS)
step 
313a) but who had avoided admission. We identified
these nine dissonant cases13 in the hospital asthma clinic
and a general practice (box 1).
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Initially we interviewed a maximum
variety sample13 of patients' general practitioners from
practices with high and low admission rates for asthma, and from
singlehanded and group practices. As recruitment proceeded, we extended
sampling to include practices where patients described particularly
good or poor relationships with their doctors. In total, we interviewed 17 general practitioners from six singlehanded, four two-partner, and
six group practices.
Hospital clinical staff and out of hours primary care
servicesWe identified hospital and out of hours factors that
might influence admission by interviewing five doctors from Newham
accident and emergency department, the hospital asthma specialist
nurse, and two doctors working for the local Healthcall organisation.
Interviews
With their informed consent, GK interviewed patients in
their chosen language (variously Punjabi, Hindi, Urdu, Gujarati, and
English), usually on hospital wards. A topic guide covered experiences
of admission and contributing factors, coping with asthma, causes of
exacerbations, and relationships with clinicians (Appendix ). Interviews
were taped, translated where necessary, and transcribed verbatim. CG
interviewed the general practitioners, covering events leading to
admission, their knowledge of the patient, and practice strategies for
managing asthma (Appendix ).
Data analysis
We modified the critical incident technique14 to include elements of the framework approach,15 allowing
analysis of interplay of identified factors. A multidisciplinary team
(sociologist, anthropologist, and primary and secondary care doctors)
met regularly to analyse data. Two researchers coded interviews
independently before entry on a database. We divided patients'
transcripts into six narrative threads, a category summarising
influences on admission, and events leading to admission. We divided
general practitioners' transcripts into practice organisation, asthma
strategy, doctor-patient relationship, cultural attitudes to asthma,
and events leading to admission. We generated a list of influences on
admission mentioned, akin to the product of the original critical
incident method.
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Results |
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Top
Abstract
Introduction
Participants and methods
Results
Discussion
Appendix
References
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We identified 60 influences on hospital admission,
illustrating the complexity of participants' experience (table).
Patients' statements about cognition, education, and behaviour were
striking for their strength or consistency across and within
interviews. We present data in three sectionspersonal influences,
health professional influences, and access to primary
care.
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Personal influences
Patients described asthma attacks ranging from severe acute
episodes causing immediate admission to exacerbations lasting weeks. As
well as citing causes such as infections and pollution, many patients
described adverse social circumstances and reckoned stress a cause of
attacks"I am here about nine years now, and they are saying that
`You have to go' [be deported]. . . That's why
I'm really stressed. . . That may be the cause" (34 year old Bangladeshi Hindu man).
"What do you do to control your
asthma? Nothing really. Just salbutamol isn't it" (34 year old
Bangladeshi Hindu man)with relatives managing attacks on a patient's
behalf or acting as mediators. Some statements by south Asian patients
seemed resigned"The illness is here, it was going to happen" (45 year old Pakistani Muslim woman)suggesting a particular attitude to
illness in general and their response to it. Many white patients seemed
more personally proactive and spoke of control in the first person (box
2).
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"Pumps, there are
so many different onesblue, brown, greenI put the machine on as
well. I don't know what is happening" (60 year old Punjabi Hindu
woman). In particular, the concept of preventive medication was
described by only one south Asian patient (who used only salbutamol)
but was familiar to white informants. One white man illustrated his
understanding by drawing a distinction between drugs for headaches and
those for asthma (box 2). Although reference to formal management plans
were rare, white patients frequently described increasing the use of a
corticosteroid inhaler during an attack; this was absent from south
Asians' accounts. Sole use of reliever inhalers or nebulisers or
non-specific use of many inhalers was described by some white patients
but by all the south Asians interviewed.
The concept of using systemic corticosteroids to abort an exacerbation
was mentioned by only one south Asian man (his general practitioner
declined his request) but was common among the white patients
interviewed. Some started corticosteroid tablets at home, and others
contacted their general practitioner urgently to obtain them. One even
sought intravenous steroids"When I'm really bad, like, I go to the
doctor's. He puts it in the vein, and it goes through the bloodstream
quicker" (55 year old white woman).
Patients often held extreme views of their general practitioners.
Although patients from both ethnic groups had experience of doctors
they felt were inadequate"He's a bitch. He's useless. He's too
busy, he says. He works two hours in the morning and two hours in the
evening surgery" (60 year old white woman (b))overall there were
qualitative differences in relationships with general practitioners.
Some white informants said how long they had been registered with the
same doctor and that they were on first name terms"He knows me so
well" (55 year old white woman). They valued continuity and personal
care"He's the man who's looking after me, you know" (65 year
old white man (a)). This familiarity was not evident in the accounts of
south Asian patients, whose statements were less personal"He is
neither good nor bad. He is 50:50" (45 year old Pakistani Muslim
man)and more functional, for example, that their general practitioner
spoke the same language, would visit if necessary, or might telephone
to check they were well.
Although there were some similarities in lifestyle and use of
complementary asthma treatment by patients (such as relaxation techniques, homoeopathy, Chinese herbalism, home acupuncture kits), there were important differences. Some south Asians used traditional medicines or dietary changes consistent with Islamic or ayurvedic humoral systems, particularly hot food spices such as ginger or turmeric, reflecting a view that cold foods were a cause of asthma. These were used in addition to, and rarely instead of, Western drugs.
By contrast, white patients mentioned self help (helplines, videos, and
books), lifestyle changes (stopping smoking, avoiding passive smoking,
exercise, recreation, taking vitamins), and peak expiratory flow monitoring.
Patients with severe asthma who had not been admitted to hospital
Both white and south Asian patients who had avoided
admission talked confidently about controlling asthma, understood the
concept of preventive medication, and trusted their general
practitioner or the local asthma specialist nurse"The consultant
[specialist] nurse at the asthma clinic, she's been very helpful,
saying `Well if you've got a bad attack you can take X amount dosage
of salbutamol' and things like that" (42 year old white woman).
Support from relatives generated control and confidence, rather than
simply having someone to mediate. Most patients had confidence to
experiment with self care. The medical model of self management was
common (box 3).
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Health professional influences
General practitioners' attitudes towards self management
and systemic corticosteroids
Self management plans were seen by general practitioners as
impractical, the level of understanding required being beyond most
patients. Many were wary of using systemic corticosteroids"I don't
use courses of steroids, for the simple reason . . . I
just leave them to the hospital" (general practitioner of 57 year old Gujarati Muslim woman)let alone allowing patients the responsibility to use them at home. One patient said: "He made me sign; he said, `You are taking steroids,' and he wrote a letter and put paper and
said, `Sign here.' I didn't know, then afterwards he read out what
he made me sign. He said, `You are taking steroids out of your own
will. If there is an effect then there will be no action against me.'
This is my GP" (65 year old Punjabi Sikh woman).
Views of accident and emergency doctors
Accident and emergency doctors asserted that patients were
admitted on the basis of clinical severity alone"Well, I don't
know much about people's backgrounds when they come in. I haven't got
a lot of time to get into their social history . . . My
two biggest [criteria] are pulse and respiratory rate" (accident
and emergency senior house officer).
Access to primary care during asthma attacks
Easy access to primary care
Patients gaining easy access to primary care during
exacerbations described good relationships with their general practitioners. White patients predominated in this group; they had
confidence to control asthma and were proactive, negotiating contact
with primary care themselves and rarely involving relatives. The urge
to contact their general practitioner (rather than go straight to
hospital) was reinforced by previous experience"I prefer going to
my GP . . . you know because he wants to see me" (20 year old white woman).
"Well I have known her, in my list,
since 1982. [I] look at all the histories, I made a note: `Father is
asthmatic, child as an infant had eczema' . . . I made
a diagnosis of bronchial asthma." (Interviewer) So you made the
original diagnosis? "In 1983we go back quite a long time"
(general practitioner of 20 year old white woman).
"When I started with him, giving up [smoking] was the major
issue." (Interviewer) How would you describe your relationship with
this chap? "I sponsored him [to run a marathon]
. . . I'd say I have a fairly good relationship with
him" (general practitioner of 32 year old white
man).
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Difficult access to primary care
Patients describing difficult access to primary care during
asthma attacks were registered with practices with high admission rates
for asthma (median admission rate 55th of 67 Newham practices, compared
with 14th for easy access group). Most such patients were south Asian.
Difficulties included the doctor declining to visit, telling the
patient to arrange admission themselves, or giving telephone advice or
a prescription in place of a face to face consultation, and a
receptionist preventing patients speaking to their doctor. Family
members (including children) either mediated contact with the general
practitioner or were consulted as an alternative (box 4). General
practitioners described basic asthma strategies, with regular review as
a basic aim, but without prioritising asthma, targeting high risk
patients, or referring to partnerships of care. A lack of nursing
support for some practices led to a sense of desperation"Our
practice nurse has gone. I can only do [anything] when they come and
sit in front of meif they come. If they don't come I'm helpless"
(general practitioner of 57 year old Gujarati Muslim woman).
Direct self referral to hospital
Patients in this group had exacerbations of more sudden
onset (median duration of attacks before admission 2.5 days, with many
admitted within 24 hours, compared with 7 and 14 days respectively for
groups with easy and difficult access to primary care). White and south
Asian patients called ambulances to get immediate care. Many had
previous admissions and considered hospital to be the best place to be,
and some had experience of poor access to primary care (box 4). General
practitioners of these patients mostly described basic practice asthma strategies.
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Discussion |
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Top
Abstract
Introduction
Participants and methods
Results
Discussion
Appendix
References
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This study takes a patient orientated rather than biomedical approach to understanding hospital admission for asthma. In comparing two ethnic groups we do not cast the behaviour of the white patients as normative. Indeed, few patients typified the medical model of asthma self management. We are aware of dangers of stereotyping behaviour in ethnic groups, as well as problems in aggregating groups into classifications that may obscure cultural differences. None the less, distinctions emerged in accounts of south Asian and white patients that are consistent with other work 1 16 and which could explain differences in risk of admission.
South Asian and white patients admitted with asthma differed in their confidence to control asthma, their understanding and use of medication, and their confidence in their general practitioners. The patients (frequently white) with confidence to manage exacerbations had good access to general practitioners with well developed practice strategies for managing asthma. These strategies emphasised policies to avoid admission, targeting of high risk patients, and a supportive approach. Good access to primary care is associated with reduced risk of hospital admission.17 Our findings are consistent with those of Clarke et al, who reported that a behavioural intervention for doctors that promoted a partnership style of consulting increased patients' confidence and reduced their use of health services.18 Developing partnerships with doctors that lead to better asthma control might be more difficult for some south Asian patients, either because doctors' espousal of Western medical concepts (such as use of regular prophylaxis) may impede a partnership relationship or because the partnership model itself may conflict with beliefs about what is an appropriate doctor-patient relationship.
Patients' descriptions of their confidence to control asthma bear some similarity to the concepts of self efficacy in social-cognitive theory and patient enablement. 19 20 Self efficacy describes an individual's confidence to carry out an activity and is a good predictor of success in self care initiatives.21 The south Asian patients admitted to hospital in this study were often less confident, even resigned, about controlling asthma compared with the white patients. This could reflect either an intrinsic cultural characteristic or the difficulties of coping with asthma in deprived social circumstances where racism is common and health services are often inadequate and inappropriate. Two observations support the latter view. Firstly, south Asian patients occasionally contrasted their poor asthma control in Britain with better control in India or Pakistan. Secondly, the south Asians and white patients we interviewed who had not been admitted showed similar confidence to control asthma and to experiment with new approaches.
Understanding and use of asthma drugs
Use of systemic corticosteroids and self management education reduce the risk of hospital admission with
asthma.
22 23
That south Asian (and some white) patients
seemed unaware of the roles and benefits of systemic corticosteroids
and preventive treatment in exacerbations clearly made admission more
likely. Moudgil et al reported that an educational intervention
provided by a south Asian respiratory specialist reduced use of
healthcare services for asthma in white but not south Asian
patients,11 suggesting differences in how the same
information is understood and acted on. Further work should determine
how cultural barriers between patient and clinician hinder education.
Other factors
Although our sample was small, our study suggests some
factors may be less important than previously thought. Firstly, language problems were rarely cited. Many south Asians in Newham have a
good command of English and some local general practitioners speak
Asian languages. Difficulties of access probably relate to a range of
factors including organisation and attitudes within primary care as
well as power issues between general practitioners, staff, and patients
in areas such as race, class, religion, and sex. Secondly, singlehanded
practices were capable of sophisticated asthma care, provided they were
adequately resourced. Thirdly, south Asian patients referred themselves
to hospital with similar reasons and frequency as white patients.
Fourthly, use of traditional medication by south Asian patients was by
no means ubiquitous and rarely to the exclusion of Western drugs.
Fifthly, we found no evidence of an "ethnicity filter" at the
accident and emergency department that might increase the likelihood of
admission for south Asians. Sixthly, we found no difference in
socioeconomic status that might explain differences between our two
groups. Seventhly, we did not detect a gradient in control and
confidence reflecting first to third generational status of south
Asians. Finally, we found no evidence of variations in behaviour
between south Asian groups.
Conclusions
General practices with south Asian patients may benefit
from interventions that encourage the development of sophisticated
asthma strategies including admission avoidance policies and
partnership styles of consultation. A better understanding of the
meaning of asthma in south Asian groups should contribute to
educational interventions that promote the concepts of preventive treatment, self care, and the benefit of systemic corticosteroids.
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Acknowledgments |
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We thank all the participants; Patricia Sturdy, Ian Jones, and Keith Meadows for help developing the original idea; Jeannette Naish for advice on sampling and help identifying patients; Dorcas MacLaren for providing practice admission rates; Tanya Price and Mei Chung for administrative support; and Colin Bradley for observations on the use of the critical incident technique.
Contributors: CG conceived and designed the study, interviewed general practitioners, and wrote the first draft. SH and GF contributed to the initial design. MG provided methodological development and review of sampling, data collection and analysis. GK interviewed patients, translated and coded transcripts, and developed the database. All authors contributed to analysis and revisions of the paper. CG is the guarantor for the study.
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Footnotes |
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Funding: The National Asthma Campaign.
Competing interests: None declared.
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Appendix: Interview topic guides |
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Top
Abstract
Introduction
Participants and methods
Results
Discussion
Appendix
References
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Interview topics for patients
1. Access to general practitioner during an asthma
attack
- Whom do you contact when you get a bad asthma attack, your GP or the hospital?
- Does distance from the GP surgery and distance from accident and emergency department make any difference?
- What would your GP do if you contacted them by phone during an attack?
- Do patients have problems in receiving repeat prescriptions?
2. Opinions about site of best care
- Is your asthma attack better managed by the GP or in hospital?
3. Choice of practice
- Why did you register with your practice?
4. General asthma care in the general practice
- What does your doctor/practice provide especially for their asthma patients?
- Does the GP ever ask to see you before allowing a repeat prescription?
5. Health beliefs about asthma
- What do you think caused your asthma?
- What do you think caused this asthma attack?
- What do you do when you feel an attack coming on?
- How do you know?
- How do you usually attempt to control your asthma?
- How typical/different was this last attack?
- What do the different medicines do to your body/breathing?
- Do they harm you in any way?
- Is it better to use tablets, injections or inhalers to control asthma?
- Is it better to take medicines for asthma regularly or only when you get an asthma attack?
Interview topics for general practitioners
1. Issues relating to out of hours care
- How are patients with acute asthma managed out of hours in your practice?
- How do you manage a call from a patient with an asthma attack?
- Do you routinely use a deputising service, a GP cooperative, or cover your own visits? How does your choice affect management of patients with acute asthma out of hours?
- What factors affect your threshold for referral of patients to hospital?
2. Attitude to and management of high risk asthma patients in the
practice
- Do you have any systematic methods of identifying and managing patients with bad asthma?
3. General attitude to asthma management
- Do you feel you manage to cope with the workload presented by your asthma patients?
- What are the difficulties you face?
4. GP views about their asthma patients
- Who do you see as the "experts" in asthma care?
- Who do your patients see as "experts" in asthma care?
- Are your patients good at assessing the severity of their asthma symptoms and understanding their asthma medication?
5. Cross cultural factors and ethnicity
- How far do you consider the ethnicity of your patients with asthma affects the way they use your surgery or the hospital for acute asthma care?
6. The admitted patient
- Tell me about your patient who was admitted
- How well do you know them?
- How would you describe your approach to their asthma management?
Interview topics for out of hours deputising doctors
1. Issues relating to out of hours care
- How are patients with acute asthma managed out of hours?
- How do you manage a call from a patient with an asthma attack?
- What factors affect your threshold for referral of patients to hospital?
2. Deputising doctors views about asthma patients
- Who do you see as the "experts" in asthma care?
- Who do your patients see as "experts" in asthma care?
- Are the asthma patients you visit good at assessing the severity of their asthma symptoms and understanding their asthma medication?
3. Cross cultural factors and ethnicity
- How does the ethnicity of asthma patients that you visit affect the way they use the deputising service, their surgery, or the hospital for asthma care?
Interview topics for accident and emergency doctors
1. Issues relating to asthma care
- How are patients with acute asthma managed in Newham accident and emergency department?
- What factors affect your threshold for admission to hospital?
- Does knowledge of the patient's general practice and the services it provides affect the way you manage an episode of acute asthma, in particular your threshold for admission?
2. Cross cultural factors and ethnicity
- How does the ethnicity of asthma patients who attend the accident and emergency department affect the way they use the service?
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References |
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Top
Abstract
Introduction
Participants and methods
Results
Discussion
Appendix
References
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(Accepted 19 July 2001)
© BMJ 2001
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