Asthma in Children Under 5 Years in Rural Kyrgyzstan: A Diagnostic Vacuum? a Qualitative FRESH AIR Study

Abstract

Background: Worldwide, asthma is the most frequent non-communicable disease in childhood, often starting in infancy. However, asthma is underdiagnosed in children <5 years of age (Under-5s) in low and middle-income countries. Aims: This study explored perceptions of, and reasons for, underdiagnosis of asthma in Under-5s in rural Kyrgyzstan. Methods: Semi-structured qualitative interviews with 22 rural primary care health professionals and 13 caregivers to Under-5s with recurrent lower respiratory tract illnesses. Results: Most health professionals and caregivers perceived asthma as a severe, debilitating, and potentially fatal disease in young children. None of the health professionals had diagnosed any Under-5s with asthma. In the health professionals’ biomedical understanding, asthma occurs predominantly in adolescents and adults, and consists of attacks of respiratory distress, with mandatory heredity and allergy. The health professionals veered away from the asthma diagnosis to avoid scaring parents, and they replaced the diagnostic vacuum with infectious diagnoses. Surprisingly, stigma regarding the population with asthma appeared to be uncommon. Most caregivers were receptive to the idea of treatment with inhaled medication and to the statement that asthma could also be a mild disease. Conclusion: The apparent systemic underdiagnosis of asthma in rural Kyrgyzstan seemed self-perpetuating. The misconceptions and dated diagnostic criteria and tradition had no provision for asthma in Under-5s; therefore, few children were diagnosed with asthma. This reinforced the inappropriate fear and belief in society that asthma is a rare, severe, and debilitating disease. Training of health professionals and providing information to the public should address the current perception of asthma and raise awareness that asthma is often a mild and treatable disease.

Gaps in asthma diagnosis and treatment in low- and middle-income countries

“…Asthma is associated with several stigmata due to which, patients are not willing to accept the diagnosis ( 6 ). Patients and their care givers believe asthma to be a debilitating condition, incurable, often fatal and they prefer not to have a diagnosis of asthma ( 7 ). In LMICs, societal and cultural norms are at odds for asthma particularly if it's a woman suffering ( 6 ).…”

“…Maternal smoking was the only independent risk factor associated with hospital admissions due to asthma exacerbation in children in Columbia ( 30 ). In absence of a family history of atopy, lack of knowledge of these environmental factors that increase the risk of asthma, can lead to denial of the diagnosis ( 7 ).…”

“…The heterogenous presentation of asthma is often confusing. Asthma is inappropriately perceived as a disease of breathlessness and wheeze, mandatorily associated with family history of allergy ( 7 ). In LMICs, pediatric asthma cases are often misdiagnosed as pneumonia or bronchiolitis ( 35 ).…”