Authors:

Fatoumata Diallo¹, 

Kofi Mensah²,

Amina Traoré³

¹Kayes District Hospital, Mali | ²Korle Bu Polyclinic, Ghana | ³San Pedro Regional Hospital, Ivory Coast

Abstract

Asthma remains a significant but under-recognized health issue across Western Africa. Despite growing urbanization and environmental risk factors, asthma continues to be underdiagnosed and insufficiently treated in many primary healthcare settings. This multisite analysis investigates the extent and consequences of underdiagnosis and treatment delays among asthma patients in Mali, Ghana, and Ivory Coast. Data collected from 450 patient records and 75 healthcare professionals across nine primary facilities reveals diagnostic gaps, limited provider training, and constrained access to essential asthma medications. Urgent policy-level interventions, including training, diagnostic protocols, and improved access to inhalers, are recommended.

Introduction

Asthma is a chronic inflammatory disease of the airways that causes recurrent episodes of wheezing, breathlessness, and coughing, particularly at night or early morning. Globally, over 262 million individuals suffer from asthma, with a disproportionate burden in low- and middle-income countries (WHO, 2021). In sub-Saharan Africa, the prevalence of asthma is increasing, especially in urban centers, due to rising air pollution, indoor smoke exposure, and limited healthcare infrastructure (Adeloye et al., 2013; Ait-Khaled et al., 2007).

In Western Africa, primary healthcare facilities are the first point of contact for most asthma patients. However, these facilities often lack the capacity for proper diagnosis and management (Asher et al., 2006; De-Graft Aikins et al., 2010). The reliance on symptom-based assessment without spirometry, coupled with inadequate training of healthcare personnel, leads to frequent underdiagnosis and delayed or inappropriate treatment (GINA, 2020).

Underdiagnosed asthma contributes to increased morbidity, missed school and work days, and a significant economic burden on families and the healthcare system (Bahadori et al., 2009; To et al., 2012). Furthermore, delayed or inappropriate treatment increases the risk of severe exacerbations, hospitalizations, and even premature death (Masoli et al., 2004).

This study by Diallo, Mensah, and Traoré investigates the current diagnostic and treatment practices in primary healthcare facilities across three Western African countries: Mali, Ghana, and Ivory Coast. It aims to quantify underdiagnosis, identify systemic barriers, and recommend strategies to enhance asthma care.

Methods

Study Design and Settings: A multisite, retrospective, and cross-sectional study was conducted in nine primary healthcare facilities (three per country) from July to December 2024. Facilities were selected based on size, patient volume, and urban-rural mix.

Data Collection: Patient records (n = 450) from the past 12 months were reviewed to assess asthma diagnosis, severity classification, and treatment. Structured interviews were conducted with 75 healthcare providers, including doctors, nurses, and community health officers, to evaluate diagnostic capacity, training, and perceived barriers.

Inclusion Criteria: Patients aged 5 and above with respiratory complaints such as chronic cough, wheezing, or breathlessness. Exclusion included those with known tuberculosis or cardiac disease.

Variables Assessed:

• Frequency of recorded asthma diagnoses

• Use of diagnostic tools (spirometry, peak flow meters)

• Availability and prescription of asthma medications (SABA, ICS)

• Referral rates to tertiary centers

• Healthcare provider knowledge and confidence in managing asthma

Data Analysis: Quantitative data were analyzed using SPSS v27. Descriptive statistics, chi-square tests, and logistic regression were used to determine associations. Qualitative data from interviews were coded thematically using NVivo 12.

Results

Diagnostic Gaps: Out of 450 patient records with respiratory symptoms, only 97 (21.6%) had an asthma diagnosis. Among the remaining 353 patients, 147 (41.6%) met clinical criteria suggestive of asthma but were undocumented.

Only 12% of facilities had functional peak flow meters, and none used spirometry. Diagnosis was primarily symptom-based, often misclassified as bronchitis or pneumonia.

Treatment Delays and Gaps: Of the 97 diagnosed asthma cases:

• 49% received only short-acting beta-agonists (SABA).

• 33% were prescribed oral corticosteroids instead of inhaled corticosteroids (ICS).

• Only 18% received guideline-based maintenance therapy (ICS + LABA).

Provider Knowledge and Systemic Challenges: Only 27% of providers had received asthma-specific training in the last five years. Barriers cited included:

• Lack of diagnostic tools (86%)

• Unavailability of essential inhalers (64%)

• Inadequate national guidelines or training materials (51%)

Country Comparisons:

• Ghana had the highest asthma recognition rate (29.3%), followed by Ivory Coast (22.6%) and Mali (13.1%).

• Ghanaian facilities reported better access to inhalers, partly due to support from international partners.

Discussion

This study confirms a significant underdiagnosis of asthma across Western Africa’s primary care settings, consistent with previous findings from other LMICs (Kirenga et al., 2018; van Gemert et al., 2011). Symptom-based approaches without objective confirmation contribute to diagnostic errors and poor disease management.

Underutilization of inhaled corticosteroids remains a persistent challenge, echoing WHO’s assessment of essential medicine gaps in LMICs (WHO, 2017). This leads to increased reliance on oral steroids and beta-agonists, offering temporary relief but inadequate long-term control (GINA, 2020).

The lack of diagnostic infrastructure—particularly spirometry—is alarming. Studies show that accurate diagnosis significantly improves asthma outcomes and reduces unnecessary antibiotic use (Pinnock et al., 2017; Osman et al., 2018).

Furthermore, the limited training opportunities for frontline healthcare workers undermine efforts to improve respiratory care. Task-shifting and decentralization efforts must include competency-based training modules and refresher courses (Licensing & Training Board Reports, 2019).

Multilateral collaboration is essential to implement asthma care packages that are scalable and sustainable. Community-based programs in Ethiopia and Kenya have shown promise in empowering non-physician providers to manage asthma effectively (Mortimer et al., 2017; Bloomfield et al., 2019).

Conclusion

Asthma remains underdiagnosed and insufficiently treated in Western African primary healthcare facilities. Structural limitations such as inadequate diagnostic tools, lack of provider training, and poor access to medications perpetuate this public health gap. Immediate actions are needed to integrate asthma protocols, enhance training, and ensure affordable access to inhalers.

Improving asthma outcomes in the region requires political will, investment in primary healthcare infrastructure, and community-level awareness. With a coordinated response, it is possible to reduce the burden of uncontrolled asthma and improve the quality of life for millions across Western Africa.

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