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Year : 2017  |  Volume : 20  |  Issue : 5  |  Page : 566-572

Relationship between knowledge and quality of asthma care among physicians in South-West Nigeria

1 Department of Internal Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
2 Department of Community Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
3 Department of Internal Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
4 Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Kwara, Nigeria
5 Department of Family Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria

Date of Acceptance12-Jun-2016
Date of Web Publication17-May-2017

Correspondence Address:
B Adeniyi
Department of Internal Medicine, Federal Medical Centre, Owo, Ondo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.206363

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Introduction: Adequate knowledge of asthma management and adherence to international guidelines are known to increase the quality of care offered by Physicians. We conducted this study to assess the level of asthma knowledge and quality of care among physicians practicing in Ondo State. Methods: We conducted a cross sectional survey of 96 physicians from various specialties participating in a continuous professional development (CPD) lecture using adapted questionnaires. Result: Respondents ranged in age from 23-62years (42.5±19.4). There were more male (70%). The minority (17%) had additional postgraduate medical qualifications. There was a high distribution of correct answers for individual knowledge questions. The greatest areas of knowledge gaps appeared in diagnostic instruments, asthma severity and drugs. We observed gaps regarding the use of GINA guidelines (6%) and prescribing combined inhaled steroid and long acting bronchodilator for patients who are not controlled on inhaled steroid alone (29%). A large number of the respondents do not confirm the diagnosis of asthma by spirometry (32%). Only 8% of the respondents with high knowledge reported a corresponding high quality of Asthma care. Conclusion: We concluded that although physicians in South-West Nigeria appear to have good knowledge, there are areas of gap in the quality of asthma care with regards to standard guideline. There is need for constant training and re-training of physicians in order to keep them up to date with international guidelines. In addition, increase access to diagnostic facilities and adapting international guideline to local realities will help improve standard of Asthma care.

Keywords: Asthma, knowledge, practice

How to cite this article:
Adeniyi B, Ilesanmi O, Obaseki D, Desalu O, Betiku B, Erhabor G. Relationship between knowledge and quality of asthma care among physicians in South-West Nigeria. Niger J Clin Pract 2017;20:566-72

How to cite this URL:
Adeniyi B, Ilesanmi O, Obaseki D, Desalu O, Betiku B, Erhabor G. Relationship between knowledge and quality of asthma care among physicians in South-West Nigeria. Niger J Clin Pract [serial online] 2017 [cited 2022 Nov 26];20:566-72. Available from:

   Introduction Top

Bronchial asthma is one of the commonest chronic respiratory diseases worldwide.[1] It contributes significantly to morbidity and mortality of noncommunicable respiratory diseases. There is wide variation in the global prevalence of asthma; however, current estimates suggested that there are over 300 million persons with asthma in the world with an expected increase to 400 million by the year 2025.[2]

In Africa, asthma cases were estimated at 34.1 million (12.1%), among children <15 years, 64.9 million (11.8%) among people aged <45 years, and 74.4 million (11.7%) in the total population.[3]

Adequate knowledge of diseases and adherence to international guidelines are known to increase the quality of care offered by physicians.[4] These not only impact positively on disease outcomes like good asthma control and better quality of life for the patients but also help to reduce the overall burden of disease and mortality.[5]

Like many developing countries, there is a dearth of respiratory physicians in Nigeria.[6] There are about 80 respiratory physicians [6] in Nigeria to cater for a population of 170 million people. As a result, most asthma cases are managed by general physicians.

Previous studies have documented suboptimal knowledge of asthma management and poor adherence to standard guidelines among physicians;[7],[8],[9] however, we are unaware of any study among physicians in Ondo State, South-West Nigeria that has evaluated knowledge of standard asthma management and predictors of high-quality care according to the generally acceptable standard of care published in the Global Initiative for Asthma (GINA) guideline.[10]

The reason for this study was to assess the level of asthma knowledge and quality of asthma care in comparison with standard care (GINA) among physicians in Ondo State, South-West Nigeria.

   Materials and Methods Top

We conducted a cross-sectional survey of 96 physicians from various specialties participating in a continuous professional development (CPD) lecture. From roughly 700 physicians in Ondo State, Nigeria, 110 physicians attended the CPD in March 2014 at the state capital and completed an adapted, self-administered questionnaire. A total of 96 physicians had complete data and were included in our analyses. It was a two-page questionnaire divided into three parts. The questionnaire was administered and filled before the CPD and averagely took 20 min for each participant to complete. We obtained verbal consent from the physicians and officials of the Nigerian Medical Association, Ondo State.

Asthma knowledge

The knowledge questions were extracted from the summary of recommendations from the GINA and Canadian Asthma Consensus Guidelines, 2003 and questions asked in a study assessing the knowledge of bronchial asthma among primary health care physicians in Crete.[11],[12] We evaluated total knowledge and knowledge subcategories (general knowledge (five questions), symptom history [(four questions), asthma triggers (10 questions), diagnostic testing (three questions), severity of attacks (three questions), drug management (10 questions)]. Each correct response was scored as 1, giving a total possible score of 35. We summarized in percentages, the number of correct responses for individual questions for the participants. Given that asthma is a common condition with which physicians are expected to be conversant, an overall score of 75% and above was set as the cut off for high knowledge.

Asthma management

We used the previously validated Asthma Physician Practice Assessment Questionnaire,[13] which was developed by the Canadian Thoracic Society Respiratory Guidelines Committee. It consists of a 14-item list of questions with subcategories including diagnostic testing and assessment, treatment and follow-up. Each response was scored as 1 and in order to determine the level of care, a score of 80% and above was set as cut off for high-quality care.

Data analysis

We recoded missing knowledge responses to “no” (N = 6 general; N = 1 triggers; and N = 2 instrument). One person had no value for all knowledge categories except general and was categorized as missing. Data were analyzed with SPSS version 21.0. Descriptive statistics were carried out.

   Results Top

General characteristics of the doctors

Respondents ranged in age from 23 to 62 years (42.5 ± 19.4). There were more males (70%) than females (30%) [Table 1]. Only 17% of the respondents had additional postgraduate medical qualifications. Nearly half (45%) had worked from 1 to 5 years in a hospital or health facility, more than half (79%) had seen asthma patients in the previous 12 months, and 52 (54.2%) had managed asthma patients on their clinic days at any time.(54%).
Table 1: Characteristics of study population based on physicians participating in an asthma continuous professional development in South-West Nigeria 2014

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Asthma knowledge and quality of care

In most of the individual asthma knowledge questions, over 80% of the respondents answered correctly [Table 2]. Fewer number of respondents recorded correct responses to questions on diagnostic instruments and asthma drugs. Only 61% of physicians knew chest radiograph should be used to exclude other diseases and only 41% of the respondents recognized adrenaline, 62% ipratropium bromide, and 52% cromolyn as appropriate therapy under GINA guideline-recognized instances.
Table 2: Percent distribution of correct responses to asthma knowledge categories

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The majority (85% and 71%) indicated they identified environmental triggers/inducers and schedule regular follow-up appointments for their asthma patients and two-third provided smoking cessation counselling to their patients [Table 3].
Table 3: Distribution of responses to “In your management of asthma patients, do you do the following”

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With respect to use of GINA guidelines in their clinical practice, only 6% reported that they follow GINA guideline. Only 29% reported prescribing a combined inhaled steroid and long-acting bronchodilator for their patients who are not controlled on inhaled steroid alone.

Only 32% of the respondents confirm the diagnosis of asthma by spirometry, while only 41% refer their patients with difficult to control asthma to a respiratory physician. Less than 50% assess their patients' inhaler technique regularly during clinic visits.

Asthma knowledge by physician categories

The knowledge of asthma by physician categories has been compared in [Table 4].
Table 4: Physician characteristics by Asthma knowledge categories (column)

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A total of 55% and 69% of those who had total high knowledge scores were among those who are aged less than 40 years and had practiced less than 20 years respectively. This same trend was also observed after the knowledge score was subdivided into specific categories of history, triggers, diagnosis, drugs, and severity. When asthma knowledge was compared with the specialties, more family physicians had high knowledge scores in all knowledge domains, that is total knowledge, symptoms, triggers, diagnostic instrument, severity, and drugs (25%, 23%, 25%, 22%, 27%, and 32% ), while those in obstetrics and gynecology had the least (5%, 6%, 6%, 5%, 5%, and 2%) respectively.

Asthma quality of care

[Table 5] summarised the quality of care offered by the physicians in their practice, which is indicated by a score of 80% and above in the practice category. In overall, diagnosis and assessment, treatment and follow-up scores, 92%, 91%, and 84% respectively of the physicians indicated they offered low quality of care.
Table 5: The association between physician characteristics and quality of asthma management

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Physicians with less than 10 years work experience constituted 53%, 52%, and 56% of those who had low quality of care score in all the domains of practice, while family medicine physicians had the highest percentage of those who offer low quality care as indicated by scores in the overall, diagnosis and assessment, treatment and follow-up categories (24%, 23%, and 23%).Association between knowledge and quality of asthma care

Only 8 (10%) of the individuals who had high overall knowledge (indicated by a score of 75% and above in the knowledge category) also had high quality of care (i.e., had 80% and above in the practice category) [Table 6]. The majority 75 (90%) of physicians who had high knowledge scores offered low quality of care (i.e., score less than 80%). None (0%) of those who had low knowledge score offered high-quality care. This relationship is however not statistically significant, P =0.32 (Fisher's exact test).
Table 6: The relationship between asthma diagnosis and treatment knowledge and the quality of asthma management

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   Discussion Top

This study sought to identify possible gaps in asthma management by physicians in South-West Nigeria. The findings in this study showed that overall knowledge regarding asthma is largely high. This was particularly informative in this study because knowledge assessment was subdivided into different domains of symptoms, triggers, diagnosis, severity, and drugs. This has the potential to identify knowledge gaps that can be specifically targeted for intervention. In a study by Obumneme-Anyim et al.[14] involving three South-Eastern states in Nigeria, good knowledge of asthma symptoms (wheeze, chest tightness, dyspnea, and cough) was also reported. The reason for this could be the new legislation in recent years requiring doctors to earn compulsory CPD points before renewal of registration thus making many more doctors to have increase assess to knowledge. The findings of high level of knowledge in this study is in contrast with what was reported by Umoh and Ukpe [7] among doctors in a tertiary hospital in Niger Delta region of Nigeria. In their study, the overall knowledge regarding management of asthma using GINA guideline was low among other physicians other than the pulmonologists.

We observed a low score regarding respondents' knowledge of the use of adrenaline, ipratropium bromide, and cromolyn in asthma treatment. This may be due to the fact that chest physicians are more likely to use these drugs than other physicians. This finding is similar with that by Hemnes et al.[8] in their study where they reported low knowledge scores in pharmacotherapy of controller medications (inhaled steroid and long acting B-2 agonists) for asthma among internal medicine residents.

Although not statistically significant, it was interesting to observe that even though the physicians had good individual knowledge scores, it did not reflect in the quality of care where most of them scored low. This is particularly of note because all the questions that were asked were the basic indices of practice recommended by the GINA guideline and thus were expected to be routine practice.

It has been observed that despite wide promulgation, clinical practice guidelines have had limited effect on changing physicians' behavior.[15] Desalu et al.[16],[17] recorded that many of the physicians in their two studies do not follow most recommendation of the GINA guideline in their practice. Our findings agree with the observations by Lindenaue et al.[18] which showed similar results among physicians managing Chronic Obstructive Pulmonary Disease.

To transform knowledge to practice, frequent continuing professional development, use of incentives for the physicians, constant reminders in form of pictures, short messages, regular audit of practice, and improved practice setting are some of the measures that may be required.[19],[20]

Regarding their work experience, a higher percentage of those who have worked for less than 20 years scored low on quality of care although they have a higher percentage of those with high knowledge score. This clearly shows that having knowledge is one thing; carrying your knowledge into practice is another.

More physicians who had managed asthma cases in the last year were observed to offer low quality of care than those who had last managed asthma patients over 12 months prior to the time of the of the study. This implies that although they see more cases frequently, this does not mean they offered optimal care.

A higher percentage of the house officers were found to offer low quality of care to their patients, while the medical officers have a higher number of them offering high-quality care. This is in agreement with the study by Umoh and Ukpe [7] where they observed that the house officers have the least knowledge scores. Although their study showed that residents in respiratory medicine had the highest scores, our study could not explore this area because there were no institutions training residents in respiratory medicine at the time of the study in the state where the study was carried out.

It was interesting to observe that the family physicians had higher total knowledge score than the internal medicine physicians. Residency training in internal medicine was recently commenced in one of the centers in the state where the study was done unlike family medicine residency, which has been ongoing for several years. This may account for the better score among family physicians.

   Conclusion Top

Although physicians in South-West Nigeria appear to have good knowledge, there are practice gaps in the management of asthma compared with standard guidelines. High level of knowledge does not appear to directly imply high-quality practice. There is need for constant training and re-training of physicians in order to keep them up to date with international guidelines and urgent need to adapt international guidelines to local practice. This will help improve the standard of asthma care.


The small sample size in this study was an obvious limitation. The study, however, may have under estimated the knowledge of the physicians in the region given that those who came for the continuing medical education are doctors who showed interest in updating their knowledge and thus likely to be more knowledgeable about asthma.


The authors wish to profoundly appreciate Dr Diana Buist for her invaluable contributions and mentorship in writing up this work.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Global Asthma Report 2014. Available from: global [Last accessed on 2016 June 24].  Back to cited text no. 2
Adeloye D, Chan KY, Rudan I, Campbell H. An estimate of asthma prevalence in Africa: a systematic analysis. Croat Med J 2013;54:519-31.  Back to cited text no. 3
Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001;39:II46-54.  Back to cited text no. 4
Feder G, Griffiths C, Highton C, Eldridge S, Spence M, Southgate L. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. BMJ 1995;311:1473-8.  Back to cited text no. 5
Obaseki D, Adeniyi B, Kolawole T, Onyedum C, Erhabor G. Gaps in capacity for respiratory care in developing countries: Nigeria as a case study. Ann Am Thorac Soc 2015;12:591-8.  Back to cited text no. 6
Umoh VA, Ukpe IE. Knowledge of the asthma guidelines among doctors in a tertiary hospital in Nigeria. Ind J Allergy, Asthma Immunol 2012;26:77-82.  Back to cited text no. 7
Hemnes AR, Bertram A, Sisson SD. Impact of medical residency on knowledge of Asthma. J Asthma 2009;46:36-40.  Back to cited text no. 8
Doerschug KC, Peterson MW, Dayton CS, Kline JN. Asthma guidelines: An assessment of physician understanding and practice. Am J Respir Crit Care Med 1999;159:1735-41.  Back to cited text no. 9
Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008;31:143-78.  Back to cited text no. 10
Becker A, Lemière C, Bérubé D, Boulet L-P, Ducharme FM, FitzGerald M, et al. Summary of recommendations from the Canadian Asthma Consensus Guidelines, 2003. CMAJ 2005;173:S3-11.  Back to cited text no. 11
Rovithis E, Lionis C, Schiza SE, Bouros D, Karokis A, Vlachonikolis l, et al. Assessing the knowledge of bronchial asthma among primary health care physicians in Crete: A pre- and post-test following an educational course. BMC Medical Education 2001;1:1-5.  Back to cited text no. 12
Boulet LP, Devlin H, O'Donnell DE. The Physicians' Practice Assessment Questionnaire on asthma and COPD. Respir Med 2011;105:8-14.  Back to cited text no. 13
Obumneme-Anyim IN, Oguonu T, Ayuk AC, Iloh KK, Ndu IK. Knowledge of Asthma among Doctors Practicing in Three South Eastern States of Nigeria. Ann Med Health Sci Res 2014;4:S253-8.  Back to cited text no. 14
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PC, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458-65.  Back to cited text no. 15
Desalu OO, Onyedum CC, Adeoti AO, Ozoh OB, Fadare JO, Salawu FK, et al. Unmet needs in asthma treatment in a resource-limited setting: Findings from the survey of adult asthma patients and their physicians in Nigeria. Pan Afr Med J 2013;16:20.  Back to cited text no. 16
Desalu OO, Adesina KT, Adeoti AO, Fadare JO, Sanya EO, Shorunmu T, et al. Physicians' prescribing pattern, perceived safety of Asthma medications and management of Asthma during pregnancy in Nigeria. Indian J Allergy Asthma Immunol 2015;29:18-23.  Back to cited text no. 17
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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