| 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.
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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
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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).
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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
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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.
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