Beyond single encounters: a mixed methods study of access to continuous asthma care using Levesque’s framework

BACKGROUND: Achieving symptom control in asthma depends on regular follow-up and access to continuous care, and inadequate control is associated with reduced quality of life and increased healthcare utilization. This study aimed to examine access to continuous care and associated factors among adult asthma patients attending tertiary care, and to explore the dynamics of continuity through patient experiences. METHODS: This is an explanatory sequential mixed-methods study within a critical realist paradigm, guided by Levesque's framework. The cross-sectional phase involved 312 participants and data were analyzed using SPSS 30.0. Chi-square test, Fisher's exact test, Student's t-test, and univariate and multivariate logistic regression were conducted. In the qualitative phase, semi-structured in-depth interviews were conducted with 12 participants selected through maximum variation sampling. Audio recordings were transcribed verbatim, coded using MAXQDA 24, and analyzed through a critical grounded theory approach. RESULTS: The mean age was 49.62 ± 14.54 years; 72.8% were female, and 17.3% were uninsured. Only 29.2% of participants had access to continuous care. The strongest determinant of continuity was receiving clear explanations about asthma (OR = 3.30). Individuals with well-controlled asthma were more likely to access continuous care than those with uncontrolled asthma (OR = 2.67). Patients reported delayed diagnoses and insufficient involvement of family physicians in asthma management. 28.2% of family physicians were unaware of the asthma diagnosis. Individuals reporting no difficulty in securing appointments were paradoxically more likely to lack continuous care (OR = 1.89). Qualitative findings suggest that difficulties in obtaining appointments with previously consulted physicians may underlie this paradox. Multimorbid patients reported significant care fragmentation due to poor coordination between institutions. Insurance status was not significantly associated, but participants reported a healthcare-related financial burden. Trust in physicians, care quality, and stigma emerged as relational factors associated with access to continuous care. Access to care was experienced as a cyclical and context-dependent process shaped by recurring barriers and facilitators and findings informed a conceptual refinement of Levesque's framework. CONCLUSIONS: Access to continuous care among asthma patients is limited. Strengthening diagnosis, follow-up, and referral processes in primary care, establishing coordination mechanisms between institutions, and expanding guideline-based practices in asthma management are necessary.