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Identifier 000445585
Title Prevention, diagnosis and treatment of chronic respiratory diseases in Primary Health Care settings : the FRESH AIR project. A focus on Crete.
Alternative Title Πρόληψη, διάγνωση και θεραπεία χρόνιων αναπνευστικών νοσημάτων στην Πρωτοβάθμια Φροντίδα Υγείας
Author Αναστασάκη, Μαριλένα
Thesis advisor Λιονής, Χρήστος
Reviewer Τσιλιγιάννη, Ιωάννα
Chavannes, Niels H.
Τζανάκης, Νικόλαος
Σουλιώτης, Κυριάκος
Παναγιωτάκος, Δημοσθένης
Παπαδάκη, Σοφία
Abstract Introduction Chronic respiratory diseases (CRDs) constitute a significant public health problem globally. According to the World Health Organization (WHO), chronic obstructive pulmonary disease (COPD) ranks as the third cause of death worldwide, while about 262 million people suffer from asthma. The greatest burden is observed in low-resource settings, with over 90% of COPD deaths and 80% of asthma deaths occurring in low-and-middle income countries. In Greece, COPD and asthma prevalence is substantial, estimated at 8.4% and 9% respectively. Evidence suggests that the situation has worsened during the recent economic crisis which significantly affected population health and risk behaviours. In particular, due to the increases in prices of conventional fuel oils, increases were observed to the use of traditional biomass-burning fireplaces for domestic heating purposes, exposing more and more people to the adverse respiratory effects of household air pollution (HAP). At the same time, the tobacco epidemic is a major issue in Greece, since the country exhibits the highest rate of smoking in the European Union (42%). Additionally, COPD and asthma place substantial financial burden on patients and the healthcare system, with the annual management costs being estimated at €4,730 and €2,281.8 per patient respectively. The economic crisis has further impacted healthcare provision in multiple ways, with lowresource rural populations, mainly served by primary health care (PHC), being disproportionally affected. Aim and objectives As part of the European (Horizon 2020) FRESH AIR project, the overall aim of the present thesis was to contribute to the improvement of prevention, diagnosis and treatment of CRDs in low-resource PHC settings on the island of Crete, Greece. The specific objectives of this thesis were: 1. To assess the clinical and economic burden of asthma/COPD, illustrating the local healtheconomic impact of CRDs. 2. To explore context-specific community beliefs and perceptions towards CRDs and examine how these are related to risk behaviours. 3. To measure levels of HAP, as a risk factor related to the recent economic crisis and examine exposure in parallel to respiratory health outcomes. 4. To assess the impact of a ‘Very Brief Advice (VBA) on Smoking’ educational module on general practitioners’ (GPs) knowledge, self-efficacy and self-reported practice 5. To assess the applicability of a remote spirometry training and feedback program (Spirometry 360) among local GPs. 13 6. To adapt a pulmonary rehabilitation (PR) programme and examine its applicability and impact on health outcomes of patients with CRDs. Methods Objective 1: Secondary data on the socioeconomic burden of CRDs in Greece were firstly collected through a scoping literature review. Additionally, primary data were collected through an observational study of 100 patients with asthma and/or COPD, consecutively visiting 10 purposively selected PHC services. Data on clinical status, healthcare expenditure and productivity losses were collected using the Work Productivity and Impairment (WPAI) questionnaire. Primary data were analyzed using descriptive statistics. Objective 2: An observational study was conducted among 200 community members from 20 randomly selected villages. Data on beliefs, perceptions and behaviours towards CRD were collected through a questionnaire based on the SETTING tool. The questionnaire introduced a vignette describing typical symptoms of CRDs which was reflected upon and used to answer the questions. Data were analyzed descriptively, while binary logistic regression was used to examine how perceptions affected risk behaviors (smoking and solid fuel use). Objective 3: An observational study with repeated design was conducted. HAP levels (PM2.5 and CO) were measured in 32 purposively selected rural households at two periods reflecting lesser (baseline) versus extensive (follow-up) domestic heating. Respiratory symptoms and clinical outcomes of household residents were assessed using questionnaires. Data were analysed descriptively. McNemar’s and Wilcoxon Signed Rank tests were used to explore differences in outcomes between measurements. Objective 4: An observational study with repeated design was conducted. The VBA on Smoking training was delivered to purposively selected general practitioners (GPs). Τheir knowledge, selfefficacy and self-reported practice were assessed before, after and one moth following the training. Changes in categorical outcomes were explored through Cochranes’ Q tests with post-hoc McNemar’s test. Changes in quantitative outcomes were explored through Friedman’s tests and post-hoc Wilcoxon Signed Rank tests. Objective 5: A qualitative study was conducted among 5 GPs who had completed the Spirometry360 training and feedback programme. GPs participated in a focus group discussion which was guided by an interview guide developed on the basis of the Chronic Care Model. Applicability of the Spirometry360 training and feedback programme was accessed in terms of reception, attendance, comprehensiveness, usefulness and added value. Data were analysed using thematic analysis. Objective 6: An observational implementation science study with repeated design and qualitative interviews with patients and stakeholders was conducted. In a rural primary healthcare centre, patients 14 with COPD and/or asthma were referred to a locally adapted PR programme. The programme comprised of 6 weeks of exercise and education sessions, supervised by a multidisciplinary team of physiotherapists, nurse and general practitioner. Patient outcomes [Medical Research Council (MRC) breathlessness scale, Clinical COPD Questionnaire (CCQ), COPD Assessment Test (CAT), St. George's Respiratory Questionnaire (SGRQ), Patient Health Questionnaire-9 (PHQ-9), Incremental Shuttle Walking Test (ISWT)] were collected before and after the programme. Changes in categorical outcomes were explored with Fisher’s exact test. Changes in continuous outcomes were interpreted based on minimum clinically important differences of (MCID). Qualitative outcomes (feasibility, acceptability) were analysed using thematic analysis. Results Objective 1: A total of 100 patients participated in the study [60.0% men, median (IQR) age: 72.5 (15) years]. Participants reported a median (IQR) of 1 (2) visit to the GP the last three months (reimbursed 93% of the time) and 0 (1) visits to the pulmonologist (reimbursed 61.0% of the time). In case of no reimbursement, the median (IQR) co-payments were 35 (14) euros for GP and 32.5 (20) euros for pulmonologist visits. Diagnostic tests and medications performed during the last year were reimbursed 78.9% and 76.5% of the time respectively. If not reimbursed, the median (IQR) out-of-pocket payments were 45 (28) and 20 (10) euros respectively. If all reported healthcare expenditure is annualized, visits to the pulmonologist represent the highest out-of-pocket payments [median (IQR) of 150 (80) euros], accounting for a raw 2.5% of annual income of patients. Among employed participants (n=15), the median (IQR) of working hours missed due to CRD during the past week was 2 (6). Overall, the median (IQR) degree of activity impairment due to CRD in the past week was 4 (5) (scored in 0-10-point Likert scale). Objective 2: Overall, 200 community members [46.5% men, median (IQR) age: 60 (31) years] were recruited. In terms of perceived identity, about half of participants (51.5%) linked respiratory symptoms presented in the vignette to a respiratory condition. While 67.5% strongly agreed that smoking causes respiratory symptoms, the respective percentage for HAP was 8.5%. In terms of susceptibility, 36% of participants reported that they were fairly likely to develop respiratory symptoms. About half (50.5%) would be fairly concerned about such symptoms and 55.5% mentioned that such a condition would affect their lives fairly much. Overall, 73.5% of the sample were smokers, while 61.0% were using biomass fuels. Smoking behaviour was inversely associated with the opinion of peoples’ social environment on the importance of seeking medical help (Odds Ratio - OR=0.628, 95%Confidence Interval - CI: 0.401-0.985) and perceived duration of disease (OR=0.742, 95%CI: 0.545, 1.010) and positively associated with perceived susceptibility (OR=2.225, 95%CI: 1.401-3.534) and presence of previous CRD diagnosis (OR=2.992, 95%CI: 1.135-7.887). Biomass fuel use was associated only with perceived control over the disease (OR=1.537, 95%CI: 1.106-2.137). 15 Objective 3: In the 32 participating households, mean PM2.5 were not significantly different between measurements (36.34 µg/m3 vs. 54.38 µg/m3 , p-value=0.60) but exceeded the WHO air quality guidelines (25 µg/m3 for 24 hours mean). Mean CO levels were found at 0.56 ppm at baseline versus 0.34 ppm at follow-up (p-value=0.414), while maximal CO levels reached 26.1 ppm at baseline versus 9.72 ppm at follow-up (p-value=0.007). These values were below the WHO cut-off points (26.6 ppm for 1 hour and 6.1 ppm for 24 hours mean). In total, 90.6% of households were using wood burning stoves or fireplaces for heating, but half of them also owned clean fuel devices. The differences between devices that were owned versus those that were used were attributed to financial reasons. In both assessments, the most frequent respiratory symptoms reported by household residents [N=42, 72.7% women, mean (SD) age: 66.8 (14.9) years] were phlegm (27.3% versus 15.2%; p-value=0.34) and cough (24.2% versus 12.1%; p-value=0.22). Less than half of participants (48.5%) knew that indoor biomass burning for heating could harm their health. Objective 4: Overall, 29 GPs attended the training [62.1% men, median (IQR) age: 44.5 (5.8) years]. A knowledge gap seemed to exist regarding their patients’ reaction to smoking cessation advice, since this question was answered correctly only by 31.0% of participants at baseline. Statistically significant increases were found in GPs’ self-efficacy in advising patients on the best methods of quitting [median (IQR) score: 3 (1) pre-training, 5 (2) post-training and 4 (2) at follow-up; p-value=0.002] and acting on patients’ decision [median (IQR) score: 3 (0) pre-training, 4 (2) post-training and 4 (1) at follow-up; pvalue=0.030]. Increases documented in GPs’ self-reported delivery of VBA elements (ASK, ADVICE, ACT) were not statistically significant. Objective 5: GPs indicated that the training increased their confidence in performing spirometry and interpreting results, pointing out its usefulness in enabling timely referral to specialized care. According to GPs, their training and practice had a direct impact on patients, as it provided the opportunity to those lacking direct access to diagnostic testing to be monitored or referred accordingly. Busy working schedules and lack of equipment were reported barriers to training attendance and subsequent practice. The on-demand and time-effective nature of the training were mentioned as facilitators to attendance, while the trust of patients to their family doctors was reported as a facilitator of continuing spirometry performance in clinical practice. Objective 6: Thirty-one patients with COPD and/or chronic asthma completed the 6-week PR programme (55.0% women, mean age of 67.2 years). Mean MRC dyspnoea scale was reduced by 1.03 points, reaching the MCID of 1. The mean sit-to-stand time was reduced by 2.41 seconds, a change close to the MCID of 2.3 seconds. The mean ISWT increased by 87.39 meters, greatly exceeding the MCID of 47.5 meters. The mean CCQ total score was reduced by 0.53 units, a difference above the MCID of 0.4. Mean CAT score dropped by almost 6 units, exceeding the MCID of 2. The mean SGRQ total score decreased by 23 units, a difference higher than the MCID of 4. The mean Karnofsky score 16 was improved by 9.67 units. PHQ-9 scores were low already from baseline, yet a reduction of 1.10 points was observed. The direct PR benefits and the necessity of implementing similar initiatives in remote areas were highlighted. Conclusions Starting with assessing the socioeconomic burden of CRDs in Greece (objective 1), the findings of this thesis suggested that relieving the indirect burden of CRDs, including activity impairment, seems to be an important area to be targeted by health interventions. Considering the factors that may influence implementation and adoption of health interventions (objective 2), the opinion of the social environment and perceived disease severity were context-specific predictors of smoking behaviour and this may be useful to consider when respective actions are designed. Levels of HAP exceeding the air quality guidelines were documented (objective 3), confirming the return to harmful practices during Greece’s austerity. This result indicates that strategies and policies to advocate for fuel poverty, raise awareness and empower communities may be of particular importance during austerity periods. In terms of addressing exposure to risk factors, there seemed to be space for raising public awareness regarding HAP (objectives 2 and 3). However, more drastic actions seem to be needed for smoking, as despite presence of awareness, rates were high in all thesis studies. The VBA training (objective 4) appeared to influence GPs self-efficacy in advising patients on smoking cessation, suggesting that, in a period following austerity, GPs’ training in providing effective smoking cessation support during their daily practice may be further examined as a strategy for addressing tobacco use and contributing to CRDs’ prevention. In terms of improving CRD diagnosis (objective 5), it was suggested that, for rural populations who may lack direct access to diagnostic options, training GPs in lung function testing may be helpful for improving under- or mis-diagnosis and facilitating proper monitoring and timely referral to specialized care. The function of a PR programme (objective 6) for the first time in the rural periphery and Greek PHC suggested that such low-cost, patient-centered and empowering approaches may be a feasible, beneficial and acceptable option for the treatment of CRD in low-resource settings. Lastly, performed studies are limited by their designs and small samples and further research is required to confirm results.
Language English, Greek
Subject Asthma
Chronic obstructive pulmonary disease
Indoor air pollution
Smoking prevention
Πνευμονική αποκατάσταση
Πρόληψη καπνίσματος
Ρύπανση του αέρα εσωτερικών χώρων
Χρόνια αποφρακτική πνευμονοπάθεια
Issue date 2022-03-30
Collection   School/Department--School of Medicine--Department of Medicine--Doctoral theses
  Type of Work--Doctoral theses
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