The socioeconomic burden of chronic lung disease in low-resource settings across the globe - an observational FRESH AIR study

BACKGROUND: Low-resource settings are disproportionally burdened by chronic lung disease due to early childhood disadvantages and indoor/outdoor air pollution. However, data on the socioeconomic impact of respiratory diseases in these settings are largely lacking. Therefore, we aimed to estimate the chronic lung disease-related socioeconomic burden in diverse low-resource settings across the globe. To inform governmental and health policy, we focused on work productivity and activity impairment and its modifiable clinical and environmental risk factors. METHODS: We performed a cross-sectional, observational FRESH AIR study in Uganda, Vietnam, Kyrgyzstan, and Greece. We assessed the chronic lung disease-related socioeconomic burden using validated questionnaires among spirometry-diagnosed COPD and/or asthma patients (total N = 1040). Predictors for a higher burden were studied using multivariable linear regression models including demographics (e.g. age, gender), health parameters (breathlessness, comorbidities), and risk factors for chronic lung disease (smoking, solid fuel use). We applied identical models per country, which we subsequently meta-analyzed. RESULTS: Employed patients reported a median [IQR] overall work impairment due to chronic lung disease of 30% [1.8-51.7] and decreased productivity (presenteeism) of 20.0% [0.0-40.0]. Remarkably, work time missed (absenteeism) was 0.0% [0.0-16.7]. The total population reported 40.0% [20.0-60.0] impairment in daily activities. Breathlessness severity (MRC-scale) (B = 8.92, 95%CI = 7.47-10.36), smoking (B = 5.97, 95%CI = 1.73-10.22), and solid fuel use (B = 3.94, 95%CI = 0.56-7.31) were potentially modifiable risk factors for impairment. CONCLUSIONS: In low-resource settings, chronic lung disease-related absenteeism is relatively low compared to the substantial presenteeism and activity impairment. Possibly, given the lack of social security systems, relatively few people take days off work at the expense of decreased productivity. Breathlessness (MRC-score), smoking, and solid fuel use are potentially modifiable predictors for higher impairment. Results warrant increased awareness, preventive actions and clinical management of lung diseases in low-resource settings from health policymakers and healthcare workers

The experiences of patients ill with COVID-19-like symptoms and the role of testing for SARS-CoV-2 in supporting them: a qualitative study in eight European countries during the first wave of the pandemic

Background Access to testing during the first wave of the COVID-19 pandemic was limited, impacting patients with COVID-19-like symptoms. Current qualitative studies have been limited to one country or were conducted outside Europe. Objectives To explore - in eight European countries - the experiences of patients consulting in primary care with COVID-19-like symptoms during the first wave of the pandemic. Methods Sixty-six semi-structured interviews, informed by a topic guide, were conducted by telephone or in person between April and July 2020. Patients with COVID-19-like symptoms were purposively recruited in primary care sites in eight countries and sampled based on age, gender, and symptom presentation. Deductive and inductive thematic analysis techniques were used to develop a framework representing data across settings. Data adequacy was attained by collecting rich data. Results Seven themes were identified, which described the experiences of patients consulting. Two themes are reported in this manuscript describing the role of COVID-19 testing in this experience. Patients described significant distress due to their symptoms, especially those at higher risk of complications from COVID-19, and those with severe symptoms. Patients wanted access to testing to identify the cause of their illness and minimise the burden of managing uncertainty. Some patients testing positive for COVID-19 assumed they would be immune from future infection. Conclusion Patients experiencing novel and severe symptoms, particularly those with comorbidities, experienced a significant emotional and psychological burden due to concerns about COVID-19. Testing provided reassurance over health status and helped patients identify which guidance to follow. Testing positive for SARS-CoV-2 led to some patients thinking they were immune from future infection, thus influencing subsequent behaviour

Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project

The COVID-19 pandemic puts health and care systems under pressure globally. This current paper highlights challenges arising in the care for older and vulnerable populations in this context and reflects upon possible perspectives for different systems making use of nested integrated care approaches adapted during the work of the EU-funded project VIGOU

Health alliance for prudent prescribing and yield of antibiotics in a patient-centred perspective (HAPPY PATIENT): a before-and-after intervention and implementation study protocol

Background Excessive and inappropriate use of antibiotics is the most important driver of antimicrobial resistance. The aim of the HAPPY PATIENT project is to evaluate the adaptation of European Union (EU) recommendations on the prudent use of antimicrobials in human health by evaluating the impact of a multifaceted intervention targeting different categories of healthcare professionals (HCPs) on common community-acquired infectious diseases, especially respiratory and urinary tract infections. Methods/design HAPPY PATIENT was initiated in January 2021 and is planned to end in December 2023. The partners of this project include 15 organizations from 9 countries. Diverse HCPs (doctors, nurses, pharmacists, and pharmacy technicians) will be audited by the Audit Project Odense (APO) method before and after an intervention in four different settings: general practice, out of hours services, nursing homes and community pharmacies in four high antibiotic prescribing countries (France, Poland, Greece, and Spain) and one low prescribing country (Lithuania). About 25 individuals from each professional group will be recruited in each country, who will register at least 25 patients with community-acquired infections during each audit period. Shortly before the second registration participants will undertake a multifaceted intervention and will receive the results from the first registration to allow the identification of possible quality problems. At these meetings participants will receive training courses on enhancement of communication skills, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting rooms, and leaflets for patients. The results of the second registration will be compared with those obtained in the first audit. Discussion HAPPY PATIENT is an EU-funded project aimed at contributing to the battle against antibiotic resistance through improvement of the quality of management of common community-acquired infections based on interventions by different types of HCPs. It is hypothesized that the use of multifaceted strategies combining active intervention will be effective in reducing inappropriate prescribing and dispensing of antibiotics.publishedVersio

The experiences of patients ill with COVID-19-like symptoms and the role of testing for SARS-CoV-2 in supporting them: A qualitative study in eight European countries during the first wave of the pandemic

BACKGROUND: Access to testing during the first wave of the COVID-19 pandemic was limited, impacting patients with COVID-19-like symptoms. Current qualitative studies have been limited to one country or were conducted outside Europe. OBJECTIVES: To explore - in eight European countries - the experiences of patients consulting in primary care with COVID-19-like symptoms during the first wave of the pandemic. METHODS: Sixty-six semi-structured interviews, informed by a topic guide, were conducted by telephone or in person between April and July 2020. Patients with COVID-19-like symptoms were purposively recruited in primary care sites in eight countries and sampled based on age, gender, and symptom presentation. Deductive and inductive thematic analysis techniques were used to develop a framework representing data across settings. Data adequacy was attained by collecting rich data. RESULTS: Seven themes were identified, which described the experiences of patients consulting. Two themes are reported in this manuscript describing the role of COVID-19 testing in this experience. Patients described significant distress due to their symptoms, especially those at higher risk of complications from COVID-19, and those with severe symptoms. Patients wanted access to testing to identify the cause of their illness and minimise the burden of managing uncertainty. Some patients testing positive for COVID-19 assumed they would be immune from future infection. CONCLUSION: Patients experiencing novel and severe symptoms, particularly those with comorbidities, experienced a significant emotional and psychological burden due to concerns about COVID-19. Testing provided reassurance over health status and helped patients identify which guidance to follow. Testing positive for SARS-CoV-2 led to some patients thinking they were immune from future infection, thus influencing subsequent behaviour

Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries

Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January-February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0-20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90-100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0-20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries

Household Air Pollution and Respiratory Health in Rural Crete, Greece: A Cross-Sectional FRESH AIR Study

Breathing polluted air is a risk to respiratory conditions. During the Greek financial crisis, the use of household fireplaces/wood stoves shifted from mostly decorative to actual domestic heating, resulting in increased indoor smoke production. We aimed to evaluate household air pollution (HAP), fuel use and respiratory symptoms in rural Crete, Greece. PM2.5 and CO were measured in 32 purposively selected rural households (cross-sectional study) at periods reflecting lesser (baseline) versus extensive (follow-up) heating. Clinical outcomes were assessed using questionnaires. Mean PM2.5 were not significantly different between measurements (36.34 µg/m3 vs. 54.38 µg/m3, p = 0.60) but exceeded the WHO air quality guidelines. Mean and maximal CO levels were below the WHO cut-offs (0.56 ppm vs. 0.34 ppm, p = 0.414 and 26.1 ppm vs. 9.72 ppm, p = 0.007, respectively). In total, 90.6% of households were using wood stoves or fireplaces for heating, but half also owned clean fuel devices. The differences between devices that were owned versus those that were used were attributed to financial reasons. In both cases, the most frequent respiratory symptoms were phlegm (27.3% vs. 15.2%; p = 0.34) and cough (24.2% vs. 12.1%; p = 0.22). Our findings demonstrate the magnitude of HAP and confirm the return to harmful practices during Greece’s austerity. Upon validation, these results can support strategies for fighting fuel poverty, empowering communities and strengthening local health systems

Rozwój badawczy w praktyce lekarza rodzinnego: zalecenia dla młodych naukowców pochodzących z krajów oograniczonych zasobach

The importance of research in family practice is widely acknowledged by leading international organizations and is recognized as a fundamental element for improving the quality of health care provision. Early-career family practice researchers often face significant difficulties related to lack of training, resources and capacity. The aim of this paper is to present the experiences gained from a country of limited resources and to provide practical guidance for young researchers to strengthen their research competencies by expanding their professional networks, utilizing funding sources and effectively presenting their research findings to the public and the international scientific community. Young family practice researchers, in particular those working in low-resource settings, may encounter many diverse obstacles from the start of their career, and actions to strengthen research capacity is needed around the world to assist in mitigating these barriers. There is, however, a great deal young researchers can achieve, despite the potential difficulties. Based on our research experience and knowledge gained in building a successful family practice research network in a low-resource country, we have attempted to offer some practical recommendations to enhance the personal competitiveness and capacity of young family practice researchers. Not to be forgotten, however, is that passion and enthusiasm will always be key factors in improving health care globally.Znaczenie badań w praktyce lekarza rodzinnego zostało powszechnie uznane przez czołowe organizacje międzynarodowe i uważane jest za podstawowy element poprawy jakości opieki zdrowotnej. Lekarze specjalizujący się w medycynie rodzinnej będący u progu swojej kariery naukowej często napotykają znaczne trudności związane z brakiem szkoleń, zasobów i umiejętności. Celem niniejszej pracy jest przedstawienie doświadczeń zdobytych w kraju o ograniczonych zasobach oraz przekazanie praktycznych wskazówek młodym naukowcom, aby zwiększyć ich kompetencje badawcze poprzez poszerzenie sieci kontaktów zawodowych, wykorzystanie źródeł finansowania i skuteczne prezentowanie wyników badań opinii publicznej oraz międzynarodowej społeczności naukowej. Młodzi naukowcy z praktyk lekarzy rodzinnych, zwłaszcza pracujący w warunkach niskich zasobów, mogą napotkać wiele różnych przeszkód od początku swojej kariery, a działania na rzecz zwiększenia potencjału badawczego są niezbędne na całym świecie, aby pomóc im złagodzić te bariery. Mimo potencjalnych trudności, wielu młodych naukowców może to osiągnąć. W oparciu o nasze doświadczenie w dziedzinie badań i wiedzę zdobytą w tworzeniu udanej sieci badań w zakresie praktyki rodzinnej w kraju o niskich zasobach staraliśmy się zaproponować praktyczne zalecenia mające na celu zwiększenie konkurencyjności osobistej i potencjału młodych badaczy praktyk rodzinnych. Nie można jednak zapominać, że pasja i entuzjazm będą zawsze kluczowymi czynnikami poprawiającymi opiekę zdrowotną na całym świecie

Πρόληψη, διάγνωση και θεραπεία χρόνιων αναπνευστικών νοσημάτων στην Πρωτοβάθμια Φροντίδα Υγείας: το πρόγραμμα FRESH AIR: εστίαση στην Κρήτη

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 low-resource 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 health-economic 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.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, self-efficacy 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 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).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; p-value=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 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.Εισαγωγή: Τα χρόνια αναπνευστικά νοσήματα (ΧΑΝ) αποτελούν σημαντικό πρόβλημα δημόσιας υγείας παγκοσμίως. Σύμφωνα με τον Παγκόσμιο Οργανισμό Υγείας (ΠΟΥ), η χρόνια αποφρακτική πνευμονοπάθεια (ΧΑΠ) κατατάσσεται ως τρίτη αιτία θανάτου στον κόσμο, ενώ περίπου 262 εκατομμύρια άνθρωποι έχουν άσθμα. Το μεγαλύτερο φορτίο παρατηρείται σε περιοχές χαμηλών οικονομικών πόρων, με το 90% των θανάτων από ΧΑΠ και το 80% των θανάτων από άσθμα να εντοπίζονται σε χώρες χαμηλού και μεσαίου εισοδήματος. Στην Ελλάδα, οι επιπολασμοί της ΧΑΠ και του άσθματος είναι σημαντικοί και εκτιμώνται στο 8,4% και 9% αντίστοιχα. Οι ενδείξεις συνιστούν ότι η κατάσταση επιδεινώθηκε κατά την περίοδο της πρόσφατης οικονομικής κρίσης, η οποία επηρέασε σημαντικά τόσο την υγεία του πληθυσμού, όσο και τις συμπεριφορές που σχετίζονται με μεγαλύτερο κίνδυνο για την υγεία. Συγκεκριμένα, λόγω της αύξησης στην τιμή των συμβατικών καυσίμων, παρατηρήθηκαν αυξήσεις στη χρήση των παραδοσιακών τζακιών καύσης βιομάζας για λόγους οικιακής θέρμανσης, εκθέτοντας όλο και περισσότερους ανθρώπους στις δυσμενείς επιπτώσεις της ρύπανσης του ενδο-οικιακού αέρα. Ταυτόχρονα, η επιδημία του καπνίσματος αποτελεί μείζον θέμα στην Ελλάδα, καθώς η χώρα παρουσιάζει το μεγαλύτερο ποσοστό καπνίσματος στην Ευρωπαϊκή Ένωση (42%). Επιπλέον, η ΧΑΠ και το άσθμα επιφέρουν ένα σημαντικό οικονομικό βάρος στους ασθενείς και το σύστημα υγείας, με τα ετήσια κόστη διαχείρισης να εκτιμώνται στα 4.730 και 2.228,8 ευρώ ανά ασθενή αντίστοιχα. Η οικονομική κρίση επηρέασε την παροχή υπηρεσιών υγείας με πολλαπλούς τρόπους, με τους αγροτικούς πληθυσμούς χαμηλών οικονομικών πόρων, οι οποίοι εξυπηρετούνται κυρίως από την Πρωτοβάθμια Φροντίδα Υγείας (ΠΦΥ), να πλήττονται δυσανάλογα. Σκοπός και επιμέρους στόχοι: Ως μέρος του Ευρωπαϊκού (Horizon 2020) προγράμματος FRESH AIR, ο γενικός σκοπός της παρούσας διατριβής ήταν να συμβάλει στη βελτίωση της πρόληψης, της διάγνωσης και της θεραπείας των ΧΑΝ σε περιοχές ΠΦΥ με χαμηλούς πόρους, στο νησί της Κρήτης. Οι επιμέρους στόχοι της διατριβής ήταν: 1.Να διερευνήσει το κλινικό και οικονομικό φορτίο του άσθματος και της ΧΑΠ, ως ένδειξη της κλινικό-οικονομικής επίδρασης των ΧΑΝ. 2.Να εξετάσει τις τοπικές αντιλήψεις και πεποιθήσεις γύρω από τα ΧΑΝ και να διερευνήσει πώς αυτές σχετίζονται με συμπεριφορές υψηλού κινδύνου για την υγεία. 3.Να μετρήσει τα επίπεδα της ρύπανσης του ενδο-οικιακού αέρα ως παράγοντα κινδύνου που σχετίζεται με την οικονομική κρίση και να εξετάσει την έκθεση αυτή παράλληλα με δείκτες αναπνευστικής υγείας. 4.Να αξιολογήσει την επίδραση της εκπαίδευσης στην «Πολύ Σύντομη Συμβουλή για το Κάπνισμα» στις γνώσεις, την αυτό-αποτελεσματικότητα και την αυτό-αναφερόμενη κλινική πρακτική γενικών/οικογενειακών ιατρών (ΓΙ). 5.Να εξετάσει τη δυνατότητα εφαρμογής ενός διαδικτυακού προγράμματος εκπαίδευσης και ανατροφοδότησης στη σπιρομέτρηση (Spirometry360) μεταξύ ΓΙ.6.Να προσαρμόσει ένα πρόγραμμα πνευμονικής αποκατάστασης (ΠΑ) και να διερευνήσει τη δυνατότητα εφαρμογής και την επίδρασή του στις κλινικές εκβάσεις ασθενών με ΧΑΝ. Μέθοδοι: Στόχος 1: Αρχικά, συλλέχθηκαν δευτερογενή δεδομένα για το κοινωνικό-οικονομικό φορτίο των ΧΑΝ στην Ελλάδα μέσω βιβλιογραφικής ανασκόπησης. Επιπλέον, πρωτογενή δεδομένα συλλέχθηκαν από 100 ασθενείς με άσθμα ή/και ΧΑΠ, οι οποίοι προσέρχονταν διαδοχικά σε 10 δομές ΠΦΥ που είχαν επιλεγεί μέσω κατευθυνόμενης δειγματοληψίας. Δεδομένα σχετικά με την κλινική κατάσταση, τις δαπάνες υγείας και τις απώλειες στην παραγωγικότητα των ασθενών συλλέχθηκαν μέσω του ερωτηματολογίου Εργασιακής Παραγωγικότητας και Αναπηρίας (Work Productivity and Impairment - WPAI). Η ανάλυση των πρωτογενών δεδομένων έγινε με χρήση περιγραφικής στατιστικής.Στόχος 2: Μια μελέτη παρατήρησης πραγματοποιήθηκε μεταξύ 200 κατοίκων από 20 τυχαία επιλεγμένα χωριά. Δεδομένα σχετικά με τις αντιλήψεις, τις πεποιθήσεις και τις συμπεριφορές γύρω από τα ΧΑΝ συλλέχθηκαν μέσω ενός ερωτηματολογίου, βασισμένου στο εργαλείο SETTING. Το ερωτηματολόγιο ξεκινούσε εισάγοντας την ιστορία ενός ατόμου με τυπικά συμπτώματα ΧΑΝ, βάσει της οποίας οι συμμετέχοντες απαντούσαν τις ερωτήσεις. Η ανάλυση των δεδομένων έγινε με χρήση περιγραφικής στατιστικής, ενώ πραγματοποιήθηκε λογιστική παλινδρόμηση για τη διερεύνηση της συσχέτισης μεταξύ πεποιθήσεων και συμπεριφορών υψηλού κινδύνου (κάπνισμα και χρήση καυσίμων βιομάζας). Στόχος 3: Πραγματοποιήθηκε μελέτη παρατήρησης με επαναλαμβανόμενες μετρήσεις. Τα επίπεδα της ρύπανσης του ενδο-οικιακού αέρα (PM2.5 και CO) μετρήθηκαν σε 32 νοικοκυριά, τα οποία επιλέχθηκαν μέσω κατευθυνόμενης δειγματοληψίας, σε περιόδους εκτεταμμένης (μέτρηση αναφοράς) έναντι χαμηλής (επαναξιολόγηση) οικιακής θέρμανσης. Τα αναπνευστικά συμπτώματα και οι κλινικές εκβάσεις των ιδιοκτητών αξιολογήθηκαν μέσω ερωτηματολογίων. Τα δεδομένα αναλύθηκαν μέσω περιγραφικής στατιστικής. Έλεγχοι McNemar’s και Wilcoxon Signed Rank χρησιμοποιήθηκαν για τη διερεύνηση διαφορών στις εκβάσεις μεταξύ των δύο μετρήσεων. Στόχος 4: Πραγματοποιήθηκε μελέτη παρατήρησης με επαναλαμβανόμενες μετρήσεις. H εκπαίδευση «Πολύ Σύντομη Συμβουλή για το Κάπνισμα» παραδόθηκε σε 29 ΓΙ, οι οποίοι είχαν επιλεγεί με κατευθυνόμενη δειγματοληψία. Οι γνώσεις, η αυτό-αποτελεσματικότητα και η αυτό-αναφερόμενη κλινική τους πρακτική αξιολογήθηκαν πριν, αμέσως μετά και ένα μήνα μετά την εκπαίδευση. Οι αλλαγές σε κατηγορικά δεδομένα διερευνήθηκαν μέσω ελέγχων Cochranes’ Q με post-hoc McNemar’s. Οι αλλαγές σε συνεχή δεδομένα διερευνήθηκαν μέσω ελέγχων Friedman’s με post-hoc Wilcoxon Signed Rank. Στόχος 5: Μια ποιοτική μελέτη διενεργήθηκε μεταξύ 5 ΓΙ οι οποίοι είχαν ολοκληρώσει το πρόγραμμα εκπαίδευσης και ανατροφοδότησης Spirometry360. Οι ΓΙ συμμετείχαν σε μια ομάδα εστιασμένης συζήτησης η οποία καθοδηγήθηκε από έναν οδηγό συνέντευξης που αναπτύχθηκε βάσει του θεωρητικού Μοντέλου Χρόνιας Φροντίδας (Chronic Care Model). Η δυνατότητα εφαρμογής του προγράμματος εκπαίδευσης και ανατροφοδότησης Spirometry360 αξιολογήθηκε επί τη βάσει της αποδοχής, της παρακολούθησης, της περιεκτικότητας, της χρησιμότητας και της προστιθέμενης αξίας του προγράμματος. Τα δεδομένα αναλύθηκαν μέσω θεματικής ανάλυσης. Στόχος 6: Πραγματοποιήθηκε μια εφαρμοσμένης επιστήμης μελέτη παρατήρησης με επαναλαμβανόμενες μετρήσεις και ποιοτικές συνεντεύξεις με ασθενείς και φορείς υλοποίησης. Σε ένα αγροτικό κέντρο υγείας, ασθενείς με ΧΑΠ ή /και χρόνιο άσθμα παραπέμφθηκαν σε ένα τοπικά προσαρμοσμένο πρόγραμμα ΠΑ. Το πρόγραμμα αποτελούνταν από 6 εβδομάδες άσκησης και εκπαιδευτικών συναντήσεων και επιβλέπονταν από μια διεπιστημονική ομάδα φυσιοθεραπευτών, νοσηλευτών και ΓΙ. Δεδομένα για τις εκβάσεις υγείας των ασθενών [κλίμακα δύσπνοιας (Medical Research Council – MRC), Κλινικό Ερωτηματολόγιο για τη ΧΑΠ (Clinical COPD Questionnaire - CCQ), Ερωτηματολόγιο Αξιολόγησης της ΧΑΠ (COPD Assessment Test - CAT), Ερωτηματολόγιο St. George's Respiratory Questionnaire (SGRQ), Ερωτηματολόγιο Υγείας του Ασθενούς (Patient Health Questionnaire - PHQ-9), Τεστ βάδισης Incremental Shuttle Walking Test (ISWT)] συλλέχθηκαν πριν και μετά τη συμμετοχή τους στο πρόγραμμα. Οι αλλαγές σε κατηγορικά δεδομένα διερευνήθηκαν μέσω ελέγχων Fisher’s exact. Οι αλλαγές στα συνεχή δεδομένα ερμηνεύτηκαν επί τη βάσει της Ελάχιστης Κλινικά Σημαντικής Διαφοράς (ΕΚΣΔ). Τα ποιοτικά δεδομένα αναλύθηκαν με χρήση θεματικής ανάλυσης. Αποτελέσματα: Στόχος 1: Συνολικά, 100 ασθενείς συμμετείχαν στη μελέτη [60.0% άνδρες, διάμεση (ενδοτεταρτιμοριακό εύρος- - IQR) ηλικία: 72,5 (15) έτη]. Η διάμεση (IQR) τιμή των αναφερόμενων επισκέψεων σε ΓΙ τους τελευτ