Results from the FRESH AIR project featured heavily in the programme of the first IPCRG Euro-Asian Scientific Conference in Bishkek, Kyrgyzstan in October, 2018.
Project partners shared their experiences and recommendations for dissemination within other countries in the Euro-Asian region. The conference also presented the opportunity for the first showing of a project film on pulmonary rehabilitation in Kyrgyzstan showing feasibility and acceptability of introducing it in remote and rural areas for people who are breathless from COPD and TB.
380 primary care delegates from medicine and nursing backgrounds attended from Kyrgyzstan, Kazakhstan, Uzbekistan, Tajikistan and the Russian Federation. There was a huge interest in the results of the project, with several full sessions covering the learning outcomes from FRESH AIR.
Sian Williams, Chief Executive Officer of the IPCRG and WP7 lead for FRESHAIR, said:
“The conference represented a wonderful opportunity to show frontline workers and policy makers why FRESH AIR was important, and to share with them our experiences and successes in Kyrgyzstan. We hope that through this important dissemination work, the project can leave a lasting legacy, not only in our partner countries but also in the wider region. We ran three parallel programmes: one for nurses, one for GPs and one for clinical teachers.
“We were also delighted to have the opportunity to talk to colleagues from the Swiss and Finnish governments about their work in Kyrgyzstan to tackle the burden of non-communicable diseases – in particular looking at clinical recruitment and education and rolling out a nationwide tobacco control programme including treating tobacco dependence. It has been very rewarding to meet and discuss with a wide variety of primary care professionals how the results of the project can be utilised now FRESH AIR has drawn to a close.”
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.
The Kyrgyz Republic has approximately 6 million inhabitants. Part of the country is at high altitude, with areas located 3,000m above sea level. In these highlands, above the treeline, where people live in yurts, locals burn animal dung for fuel for cooking and heating. They live indoors for about 8 months per year. During these months the ventilation hole in their yurts is kept closed to retain the heat, but this also increases their exposure to indoor pollution.
In the highlands, clinical centres are not easily accessible by the population, especially during winter months. The rate of smokers is alarming; nearly half of all the men smoke. More resources are needed to effectively support quit attempts.
FRESH AIR researchers from Leiden University Medical Center (LUMC) visited the Kyrgyz Republic in May 2016. The purpose of the visit was to carry out research to ensure that the implementation of evidence-based interventions that will be carried out during the project will be as suitable as possible for the area.
The delegation was joined by a multidisciplinary team of researchers from the Kyrgyz National Center of Cardiology and Internal Medicine.
During the 3-week expedition, the delegation visited eight villages and six GP centres. Before starting the research activities, the LUMC team delivered a 2-day workshop on rapid assessment to local researchers. Rapid assessment is a qualitative research approach aimed at gathering a vast amount of in-depth information in a short period of time.
The study included community members, healthcare professionals (nurses and doctors) and leaders of rural villages. The team held numerous one-on-one interviews, group interviews and observations with nurses working in the clinical centres. The team also visited rural primary care practices to observe consultations. An impressive stakeholder engagement group has been set up across the entire country who will help advise on all stages of the project, from implementation through to sharing of any findings, so that the impact of the project lasts beyond the project end. The trip was a real success and the data collected will be analysed in the next months.
Link back to FRESH AIR 1st Newsletter - December 2016
Members of the FRESH AIR team visited Crete in summer 2016 to carry out research on chronic respiratory diseases on the island. They were joined by their local colleagues from the Public Health department of the University of Crete.
Crete has approximately 620,000 inhabitants and is the most populous island of Greece. Half of the population lives in rural areas. In Crete, the incidence of chronic respiratory diseases is increasing and local healthcare professionals are finding the situation harder to manage.
The main health care provision in rural areas is delivered by primary care physicians. The FRESH AIR team visited several general practices in inland rural areas, making contact with healthcare professionals, pharmacists, local communities, heads of municipalities and religious leaders. They observed that a high number of people suffer from chronic cough, shortness of breath and breathing problems.
Preliminary data show that while primary care physicians on the island are familiar with the issues and have the right skills to treat them, the financial crisis which has affected Greece in recent years has limited access to resources. There are staff shortages and limited diagnostic tools, including spirometers. People with lung conditions sometimes find it difficult to pay for medications. One of the GPs has established a ‘social pharmacy’, in which he recycled unused medications, providing them to those who could not afford them.
The data from this research trip are being analysed. The full story will be described in a future scientific paper.
Link back to Fresh Air Newsletter - December 2016
In the country, the most commonly prescribed treatments for chronic lung disease are salbutamol inhalers (cost US$ 2-3) and inhaled steroids ($ 5-10). Ongoing maintenance treatments with inhaled steroids are out of the reach for most patients, as medicines are only partially covered by a person’s health insurance.
Pulmonary rehabilitation, based on international standards, could help improve care. Rehabilitation is already provided in the hospitals, but not for people with respiratory problems. However, pulmonary rehabilitation, performed in close collaboration with GP-run community clinics, could be a new and innovative way to tackle chronic lung conditions and symptoms such as breathlessness.
In order to understand the best ways to provide pulmonary rehabilitation programmes in Vietnam, the FRESH AIR team visited local hospitals and a medical college.
The pulmonary rehabilitation pilot project will start at the Rehabilitation and Occupational Disease Hospital in Ho Chi Minh City. The hospital offers facilities for pulmonary rehabilitation to take place, such as a large room with an open walkway, and all the necessary equipment.
Once established in this hospital, rehabilitation will be started at two further hospitals ‒ one in Ho Chi Minh City and one in Tien Giang. The FRESH AIR team visited both sites and saw the excellent facilities and met the teams who will be conducting pulmonary rehabilitation and the senior staff members. The FRESH AIR team organised one full day of training on pulmonary rehabilitation with the FRESH AIR train the trainer programme. The training was well attended, with 18 people from three hospitals, demonstrating that there is great interest in pulmonary rehabilitation. Most attendees were experienced rehabilitation clinicians. The FRESH AIR team concluded that staff from the hospital are already in a position to organise and run sessions with support from the FRESH AIR project.
The FRESH AIR training session is the first step to help Vietnam to establish international standard pulmonary rehabilitation.
The FRESH AIR team gave a presentation on the project and its aims at the Tien Giang Medical College, located in the Mekong Delta region of southern Vietnam. The College provides education to over 3,000 students and is very supportive of rehabilitation for chronic lung diseases, as it sees that such non-communicable diseases are a rising threat to health in their area.
Following the site visit, the FRESH AIR team agreed on the next steps to successfully introduce pulmonary rehabilitation in Vietnam. The protocol of FRESH AIR intervention is being updated. The first round of pulmonary rehabilitation will start in March 2017, after which the FRESH AIR team will make a second visit. The intention is to gradually roll out the service to other rehabilitation hospitals in Vietnam, and this will involve an education programme for the hospitals and the primary care referrers.
Link back to FRESH AIR 1st Newsletter - December 2016
FRESH AIR is a beautiful illustration of a "health in all policies" approach and has the potential to have a direct impact on three of the United Nations' SDGs and increase the possibility of success in at least two more.
SDG3 Ensure healthy lives and promote well-being for all at all ages
Goal 3 seeks to ensure health and well-being for all, at every stage of life. The Goal addresses all major health priorities, including reproductive maternal and child health; communicable, non-communicable and environmental diseases; universal health coverage; and access for all to safe, effective, quality and affordable medicines and vaccines. It also calls for more research and development, increased health financing, and strengthened capacity of all countries in health risk reduction and management.
FRESH AIR is tackling one of the main NCDs: chronic respiratory diseases by implementation of smoking cessation programmes, improving diagnosis of childhood respiratory problems, reducing exposure to smoke from indoor biomass, and exploring how to improve access to effective treatments including smoking cessation and pulmonary rehabilitation. We are working locally, collaborating globally to build capacity in local workforces to tackle non-communicable respiratory diseases, working with Community Health Workers in Uganda, primary care teams in Vietnam, Crete and respiratory teams in the Kyrgyz Republic. FRESH AIR is therefore is contributing to these SDG3 targets:
3.4 By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being
3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
3.a Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate
3.c Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States
SDG 4 Quality Education
Goal 4 strongly supports the reduction of persistent disparities in education. Children from the poorest 20 per cent of households are nearly four times more likely to be out of school than their richest peers. Out-of-school rates are also higher in rural areas and among children from households headed by someone with less than a primary education.
In high income countries chronic respiratory diseases have a huge impact on children's ability to attend school, and this is likely to be the case in low income countries too, compounded by other socio-economic challenges. If FRESH AIR can help communities put in place measures to tackle chronic respiratory diseases, and to engage local communities, such as Community Health Workers in learning about and sharing knowledge about lung health and clean fuel and cookstoves, it may also have an impact on SD4 targets. In particular:
4.4 By 2030, substantially increase the number of youth and adults who have relevant skills, including technical and vocational skills, for employment, decent jobs and entrepreneurship
4.5 By 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities, indigenous peoples and children in vulnerable situations
4.7 By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and sustainable lifestyles
It will also mean that communities may have a greater preparedness to benefit from SDG 7
SDG 7 Ensure access to affordable, reliable, sustainable and modern energy for all
The proportion of the world’s population with access to clean fuels and technologies for cooking increased from 51 per cent in 2000 to 58 per cent in 2014, although there has been limited progress since 2010. The absolute number of people relying on polluting fuels and technologies for cooking, such as solid fuels and kerosene, however, has actually increased, reaching an estimated three billion people. Limited progress since 2010 falls substantially short of global population growth and is almost exclusively confined to urban areas.
FRESH AIR is working with colleagues in Masindi, Uganda, and EnDev to test the implementation of cleaner cookstoves, and to reduce reliance on wood and kerosene. In the Kyrgyz Republic we are exploring what is possible and affordable to reduce reliance on the use of animal dung as the fuel for cooking and heating in the Highlands. In Crete, the challenge is the return to use of wood-burning stoves in financially austere times. The challenges in rural Vietnam are being mapped out in site visits now. By helping communities understand the health problems associated with the fuels they use, and connecting with schemes aiming to address SDG 7, FRESH AIR will help prepare communities to benefit from other SD7 interventions. In particular:
7.1 By 2030, ensure universal access to affordable, reliable and modern energy services
And by using reliable, modern energy services, there may be an impact on SDG 15 where wood is the preferred fuel:
SDG 15 Life on Land
Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss.
15.2 By 2020, promote the implementation of sustainable management of all types of forests, halt deforestation, restore degraded forests and substantially increase afforestation and reforestation globally
For more on the SDGs go to the UN website.
Executive Officer, IPCRG
In preparation for our 1st Scientific Conference in Sri Lanka in August 2017, we have been discussing the programme with our International Advisory Committee, and ensuring it is practical and applicable to the real working lives of primary care clinicians and their patients. Our colleague Monsur Habib highlighted a 2011 paper from the Departments of Pulmonary Medicine in Lucknow and Mumbai, India which suggests that in "resource-poor settings, the goal of rehabilitation may be achieved by incorporating regular unsupervised exercise in daily routine" and would give access to the 70%+ (2001 Census) of the Indian population that live in rural areas where the prevalence of tobacco dependence and COPD is also highest. It also gives a commentary on the current evidence, from a low resource setting perspective.
We hope that teams who have tried to implement such programmes will submit abstracts to our conference to share their findings and experience. Details of abstract submission: 1st Scientific Conference in Sri Lanka in August 2017
This Death in the Air infographic published by the World Bank in September 2016 raises the profile of air pollution as a global health and economic problem.
"Air pollution has emerged as the fourth-leading risk factor for deaths worldwide. While pollution-related deaths mainly strike young children and the elderly, these deaths also result in lost labor income for working-age men and women. The loss of life is tragic. The cost to the economy is substantial. The infographic below is mainly based on findings from The Cost of Air Pollution: Strengthening the economic case for action, a joint study of the World Bank and the Institute for Health Metrics and Evaluation (IHME)"
Describing the problem without solutions is not motivating. The World Bank is investing in pollution control and FRESH AIR is looking at existing health improvements and how to implement these and adapt these in different contexts.
Also offering hope is information from the European Lung Foundation, one of FRESH AIR partners, that has produced a factsheet for European healthcare professionals to explain to patients about the risk of poor air quality, putting different risks, such as active smoking and living by a busy road into context. It is written by the European Respiratory Society Environment and Health Committee and the European Lung Foundation as part of its Healthy Lungs for Life campaign that funded our original work in the Kyrgyz Republic.
Excerpt reproduced with permission, to download full infographic including suggestions for people at risk go to http://www.europeanlung.org/assets/files/factsheets/risks-air-pollution.pdf
We talk about Turning the World Upside Down where low income countries have something to reach high income countries about the delivery of health care. But is it real?
Well, here's an illustration.
In the UK we struggle to "sell" the benefits of Pulmonary Rehabilitation to payors or patients. We struggle to provide services that match the evidence because PR is often provided in church halls and community centres with very limited equipment and fewer staff. A group of 12 breathless people with COPD, each with a different body mass index, strength and knowledge in a church hall with some chairs, one set of weights and a few traffic cones. Sound familiar?
But in Uganda there's a unique project underway that may help. Having started with people who have survived TB, a PR programme is being rolled out to people with chronic lung disease in Uganda and then Vietnam, Kyrgyz Republic and Crete.
Applying the principles of implementation science, it is adapting the evidence to the local resource-poor context.
There are two main differences. Here patients do not have access to any inhaled medicines. So, we can see if PR alone can make a difference to their lives. Here, where there is no government safety net, we can also count the benefits of economic productivity and social capital.
Physiotherapist colleagues in the UK may be inspired seeing how patients can benefit and also how adaptations are made to the local context. See a link to a new film here.
For now, the key questions for me are:
- What makes people turn up?
- What makes people complete the programme?
- What elements are transferable anywhere in the world such as endurance exercises?
- What about strength exercises: the ones that train muscles to use less oxygen so more is available for breathing - how can these be calibrated to individuals with very different starting points?
For a practical background to PR see IMPRESS guide to pulmonary rehabilitation
Executive Officer, IPCRG
FRESH AIR WP7 lead