The FRESH AIR project in Greece is being implemented by a multidisciplinary research team from the Clinic of Social and Family Medicine within the University of Crete. The project is focused on primary health care (PHC) settings, and targets rural and deprived populations. At present, several research tasks are ongoing and significant progress has already been achieved.
A pulmonary rehabilitation programme was established for the first time in a rural PHC Centre in Crete. Three groups of patients with chronic respiratory diseases (CRD) participated in the programme, supervised by one general practitioner (GP), two physiotherapists and a nurse. The programme was warmly embraced by both patients and stakeholders, and may be a feasible and effective approach against CRDs in Cretan PHC settings.
Qualitative research on beliefs, perceptions and behaviours towards CRDs was performed in several rural settings, as well as in a Roma community. Preliminary data from healthcare professionals, community members and key informants has shed light into aspects of awareness, health needs and barriers to healthcare. To supplement these data, quantitative surveys are currently being conducted in randomly-selected villages and with GPs.
A ‘teach-the-teacher’ module will also be implemented in certain rural settings. GPs will be trained to teach other healthcare professionals who will teach community members on the harmful effects of smoking and household air pollution (HAP), likely to be caused by wood burning for heating. Educational materials are currently being adapted to this context.
Initial observations from rural settings emphasise the impact of the financial crisis on HAP. Although awareness may be relatively high and households may already be equipped with modern heating devices, they may not be able to afford to use them. The FRESH AIR team is also conducting observations of clinical consultations in selected PHC centres and one hospital setting, with the aim of exploring diagnostic approaches and treatment of acute respiratory illness in children under 5 years old with cough and/or difficulty breathing. Qualitative interviews with healthcare professionals, caregivers and local experts are being performed to investigate terms and concepts of childhood cough and asthma. More than half of both the quantitative and the qualitative work has been completed.
In order to explore the health economic impact of CRDs in Greece, an extensive set of secondary data has been identified. Additionally, 100 ‘Work Productivity and Impairment’ questionnaires of consecutive patients visiting selected GPs have been collected. The health economics workshop will be held in April 2017.
Several GPs have completed online training in spirometry. Participating GPs will now be able to use a modern diagnostic spirometer, which will allow them to receive feedback on each spirometry performed. GPs will also be able to attend a session on ‘Very Brief Advice on Smoking Cessation’ in May 2017.
The FRESH AIR Team in Greece has presented the project to several stakeholders nationally and in international conferences and meetings. Detailed information and results of FRESH AIR actions in Greece will be featured in future scientific papers.
Fresh air newsletter May 2017“We train providers to perform and interpret spirometry, to find and treat common chronic lung disease”
Spirometry testing, one of the most comprehensive pulmonary function tests, is an important tool in the diagnosis and ongoing management of asthma and chronic obstructive pulmonary disease (COPD). As valuable as the clinical information from this test can be, its accuracy is dependent on the technique used by the tester and the person being tested, and is often performed incorrectly if the tester has not been properly trained. Interpretation of spirometry results also requires a foundation of knowledge, reinforced by case-based practice.
In a lung specialist setting, colleagues knowledgeable in spirometry are generally available to consult with and advise. However, this support is typically missing from the primary care setting where the majority of people with asthma or COPD in low and middle income countries are treated. As a result, most people with asthma or COPD have never undergone a spirometry test. As an analogy, imagine the challenge of treating hypertension without blood pressure monitoring?
To address this gap in primary respiratory care, Professor James Stout and his team at University of Washington (UW), have developed Spirometry 360. Spirometry 360 offers remote spirometry training and feedback on technique for spirometry tests performed at a practise site over several months. Self-paced, case-based tutorials are provided for those doing the test and for those interpreting. Since 2009, this online programme has been continuously delivered to over 300 primary care practices in the USA, and to 10 other countries via the International Primary Care Respiratory Group (IPCRG) network.
FRESH AIR provides an opportunity to deliver Spirometry 360 to the project countries. Local FRESH AIR teams in Kyrgyzstan and Vietnam are translating the training materials into Russian and Vietnamese to increase the potential reach. This spring, local FRESH AIR teams in Kyrgyzstan and Vietnam will also create a studio recording of the training materials, and the UW team will then assemble them into language-specific online modules.
Professor Stout is also part of a team developing a smartphone-based spirometer known as SpiroSmart. A patient blows into the phone’s microphone, and the data is sent to a cloud-based server, where a software programme translates the tracheal sounds into a flow/volume curve, to show whether a person’s lungs are normal or obstructed, and by how much. As a result of relationships made through the IPCRG network, Dr Monsur Habib in Bangladesh and the Chest Research Foundation in India have contributed validation data for this project. This new technology is also part of the FRESH AIR project, and a usability test of SpiroSmart will be conducted in each of the four participating countries. Initially, SpiroSmart will be used to measure trends in the FEV1 (forced expiratory volume in one second), the main measure of lung obstruction. Professor Stout will be training the FRESH AIR country teams how to use SpiroSmart, and also how to collect usability data, at the 1st IPCRG South Asian Scientific Conference in August 2017 in Colombo, Sri Lanka.
Chronic respiratory disease (CRD) has been fairly low on health policy agendas, both internationally and nationally in low- and middle-income countries (LMIC). This has been understandable, given the impact of communicable diseases such as HIV, malaria and tuberculosis. But the impact and prevalence of CRDs is increasing, alongside a steady rise in life expectancy and better treatments for communicable diseases. It is now a priority to prevent and provide better treatment for CRDs.
FRESH AIR teams in Kyrgyzstan, Uganda, Vietnam and Greece are helping to raise awareness of the impact. Knowledge of the current situation is one of the starting points for drawing up national action plans and to implement effective strategies. However, national impact data on CRDs have largely been lacking. Therefore, as a first step, the FRESH AIR project is collecting national clinical and economic data on the impact of CRDs.
The FRESH AIR project is looking into optimal implementation strategies for affordable and effective interventions, such as smoking cessation, household air pollution reduction and pulmonary rehabilitation programmes. FRESH AIR local teams will then estimate the impact and cost-effectiveness of FRESH AIR actions to inform successful scaling-up of the interventions and influence national policy plans.
Workshops have been organised in Kyrgyzstan, Uganda and Vietnam on health economics, with the aim of optimising implementation and knowledge transfer. A workshop in Greece is scheduled for April 2017. Participants in the workshops have discussed the basic concepts of health economics, as well as the survey and study plans. The survey and sample sizes were adapted and tailored to the healthcare system, team capacity and environmental factors in the individual countries. Primary data is being collected locally with tools that measure interventions, as well as healthcare resource utilisation and time investment. This is filling the multiple gaps in knowledge that exist, despite using local scientific papers that have been provided by the FRESH AIR country teams.
Vietnam and Kyrgyzstan are finalising their data collection process (which involves approximately 400 in-and out-patients). A smaller sample is being collected in Greece, where data collection is more than halfway. In Uganda, despite some delays, the local team will submit their target sample in the following months. Overall, all the local teams are very enthusiastic and are doing an amazing job.
FRESH AIR partners have started to report results to the European Commission, including clinical data and data on demographics, risk factors, healthcare utilisation, quality of life, and direct and indirect costs of diagnosed respiratory patients. These will inform the use of the socio-technical allocation of resource (STAR) tool, which helps policy-makers prioritise allocation of resources to the most cost-effective interventions.
The FRESH AIR team will continue to analyse the data and plans to publish a scientific article and specific abstracts over the next few months. The team at ARTEG, led by Job van Boven, hopes that data and figures will form a good basis to tackle CRDs in national action plans and locally in policy making.