Asthma and COPD exacerbation in relation to outdoor air pollution in the metropolitan area of Berlin, Germany

Background: Ambient air pollution poses a major risk for the development and aggravation of respiratory diseases. Evidence suggests that even in low-level air pollution environments there is a risk for an increase in adverse respiratory symptoms. We examined whether variations in daily air pollution levels of nitrogen dioxide, ozone, or particulate matter in Berlin, Germany were associated with hospital admissions of chronic obstructive pulmonary disease (COPD) and asthma patients in a time series analysis. Methods: We calculated single and multi-pollutant models, investigated possible lags in effect, and analysed the influence of meteorological variables on the results. Data from January 2005 through December 2015 were used to quantify the concentration-response. Results: The risk ratio for asthma patients to be hospitalised on the same day of NO2 exposure was 1.101 per 10 mu g/m(3) NO2 increase (95% CI: 1.013 to 1.195), for COPD patients 1.123 (95% CI: 1.081 to 1.168). Neither the exposure to ozone (95% CI: 0.904 to 1.020), PM10 (95% CI: 0.990 to 1.127), nor PM2.5 (95% CI: 0.981 to 1.148) was associated with an increased risk ratio for asthma patients to be hospitalised. Risk ratios for the hospital admission of COPD patients were also not increased due to ozone (95% CI: 0.981 to 1.033), PM10 (95% CI: 0.988 to 1.032), or PM2.5 (95% CI: 0.966 to 1.019) exposure. The presented risk ratios and confidence intervals relate to the day of exposure. We found no increased hospitalisation risks with a delayed occurrence on subsequent days. Conclusions: A quantifiable, statistically significant increase in risk for asthma and COPD exacerbations owing to NO2 exposure at levels well below European regulatory limit values was observed

Prevalence and correlates of tobacco smoking, smokeless tobacco and passive smoking in Georgian adults: results of non-communicable disease risk factors STEPS survey Georgia 2016

Background Despite the growing problem of tobacco epidemic in Easter Europe and Former Soviet Union, there is a lack of national based scientific data that could serve as an evidence for appropriate policy level interventions. Methods A population-based national cross-sectional survey was conducted using the WHO STEPwise approach to non-communicable disease risk factor surveillance in aged 18-69 age group. A multi-stage cluster sample design and weighting were used to produce a national representative data for that age range. Total number of participants who took part in the survey was 5554. Results The prevalence of tobacco use, both smoking and smokeless together was 31.1%, 57.1% in men and 7.1% in women respectively. 29.9% of current tobacco users reported smoking cigarettes, among them 55.3% men and 6.6% women respectively. Biggest majority of current cigarette smokers were also defined as daily smokers, 51% men and 6.2 % women respectively. Mean age of starting smoking was reported 17.8 in men and 22.4 in women. Smokeless tobacco was used only by 0.3% of adult Georgian population, among them 0.6% men and 0.1% women respectively. 43% of all participants were exposed to passive smoking at home, about 16% at the workplace. Conclusions Tobacco use and second hand exposure to tobacco smoke was a significant public health concern in Georgia. Cigarette smoking was identified as almost exclusive form of tobacco use in Georgia. This study provides the data which can be used by policy makers to shape evidence-based policies and targeted interventions

Assessing tobacco marketing regulation implementation level in Georgia: evidence from Non Communicable Disease Risk Factors STEPS Survey Georgia 2016

Background Tobacco use continues to be the leading cause of preventable deaths worldwide; the biggest burden of it falls on low- and middle-income countries and this trend is expected to widen further in case of inaction. The overall objective of the study is to describe and analyze the findings of the Noncommunicable Disease Risk Factors STEPS Survey Georgia 2016 related to tobacco marketing regulation. Methods The current study in Georgia was a population-based STEPS survey of randomly selected adults aged 18-69 within each sex and 10-year age-group. A multi-stage cluster sample design was used to produce representative data for that age range in Georgia. A total of 5554 adults participated in the current survey. We assessed level o tobacco marketing regulation implementation in Georgia. Results Study results reported high prevalence of tobacco use in Georgian population (31.1% (95 % CI: 29.0-33.1)). Study findings showed that about half of the current smokers are exposed to anti-tobacco information on TV or radio 52.3% (95% CI: 48.9 - 55.7), whereas 35.5% (95% CI: 32.2 - 38.8) reported being exposed to cigarette marketing at points of sales of tobacco products and 4.7% (95% CI: 3.2-6.1) to any cigarette promotions. Health warnings on cigarette packs was reported to be noticed by 88.7% (95% CI: 85.8-91.6)) of current smokers; only 33% (95% CI: 25.4 - 40.7) of them reported having thought about quitting because of these warnings. Conclusions The prevalence of smoking in Georgia is high compared to other countries of the European Region and it is very likely that smoking related NCDs burden will increase. Stricter tobacco control policies coupled with anti-tobacco media campaigns can address this problem. Improved health warnings on tobacco packages and total ban of tobacco advertisement, promotion and sponsorship should be implemented in order to overcome prevailed tobacco industry marketing strategies

Current tobacco use and its associated factors among adults in Georgia: findings from Non-Communicable Disease Risk Factors STEPS Survey Georgia 2016

Background Tobacco surveys of past decades show that tobacco use prevalence is high in Georgia; According to nationwide Noncommunicable Diseases (NCDC) Risk Factors STEPS Survey 2010 30% of adult population are current tobacco users. Another Nationwide Tobacco Survey 2014 reported 28% of tobacco use prevalence among Georgian adults. However, there has been relatively little progress in systematic study of the factors associated with this high tobacco use. The current study aimed to assess the prevalence of tobacco use and its associated sociodemographic, behavioral and environmental factors in Georgia. Methods The current study in Georgia was a population-based STEPS survey of adults aged 18-69. A multi-stage cluster sample design was used to produce representative data for that age range in Georgia. The. A total of 5554 adults participated in the survey. The overall response rate was 75.7%. We assessed sociodemographics, behavioral and other health-related factors. Results The prevalence of current overall tobacco use was 31.1% (95 % CI: 29.0-33.1) which comprised of smoked tobacco use, smoked cigarettes and use of smokeless tobacco, 31.0% (95% 28.9-33.0) smoked tobacco, 29.9 (95% CI: 27.9-32.0) smoked cigarettes and 0.3 (95% CI: 0.0-0.6) use of smokeless tobacco. Smoking prevalence was significantly higher in men 57.1% (95% CI: 53.7-60.4) compared to women 7.1% (95% CI: 5.9-8.4), especially in younger age groups and with other substance abuse history (predominantly alcohol). Conclusions Despite of some efforts in the field of tobacco control, tobacco use (particularly smoking) was high in Georgia. Males, younger age groups, and population with addictions to other substances (especially alcohol) should be the primary target of behavioral interventions; The stricter implementation of tobacco control measures, including comprehensive ban of tobacco marketing and smoking in public places, improved health warnings on tobacco packages and anti-tobacco communication campaigns can have a significant positive impact on reducing growing tobacco epidemics in Georgia

Development and application of a rapid research prioritisation process for identifying health research priorities in low- and middle-income countries:the RAPID-RP stakeholder analysis

Background: Health research should be locally prioritised by key stakeholders to ensure the best use of available resources, maximum likelihood of research leading to uptake into policy and practice and relevance to the needs of the potential beneficiaries. Established approaches are complex and time-consuming, therefore not feasible in settings where prioritisation is uncommon and time is limited. Objectives: We developed and applied a simple, rapid research prioritisation approach (RAPID-RP) to elicit the views of stakeholders. Setting and participants: This was a collaboration between a multidisciplinary group of UK academics, the International Primary Care Respiratory Group (IPCRG) and primary care respiratory researchers from four low- and middle-income countries (LMIC): Brazil, China, Georgia and North Macedonia. We identified 10 topics for research prioritisation through workshops involving 26 topic, methods and local context experts, and considering the programme remit, to develop, adapt and evaluate culturally appropriate community and behavioural approaches for the prevention, early identification and management of COPD in primary care. Design and methods: In each setting, local research teams convened stakeholder groups of patients, clinicians, managers / policy makers and researchers. Each group briefly discussed the ten potential research study topics. Discussions were facilitated using short vignettes for each topic, and participants encouraged to consider importance, feasibility and equity. Individual participants rated each study on a 3-point traffic light scale, then ranked them following a facilitated discussion on what drove the ratings. The research team rated then ranked each study considering three further criteria (international novelty, potential for future funding and capacity building on a 5-point scale). Within each group, ranks were summed to create a final rank order which guided our research programme and provided insight for future projects. Results: In each country, 4-8 members attended each stakeholder group, The engagement process was completed in less than four hours and feedback was very positive, especially from patients who valued the opportunity to contribute to research decision-making about their own condition. Ranking varied to some extent between groups and settings, but there was consistency around topics that were prioritised among the top 5 in all groups (identifying efficient COPD screening test strategies, evaluations of lung age to aid smoking cessation, feasibility of locally-adapted pulmonary rehabilitation, clinical education for primary care staff) and study topics that consistently ranked low (use of e-cigarettes for smoking cessation, weight management to improve COPD symptoms and handwashing to reduce infections).Limitations: Despite attempts to maximise inclusivity and diversity, stakeholders were mainly limited geographically to the centres where researchers were based, potentially limiting generalisability of views across the countries. Facilitator styles varied and may have influenced some of the discussions and potentially the ranking.Conclusions: Despite some limitations, we demonstrated the feasibility and acceptability of the RAPID-RP stakeholder analysis for identifying locally relevant research priorities in LMIC settings.Future work: Further validation is needed for aspects of the process. We have identified some useful lessons from our evaluation of the process, to facilitate future use of this approach.<br/

Development and application of a rapid research prioritisation process for identifying health research priorities in low- and middle-income countries:the RAPID-RP stakeholder analysis

Background: Health research should be locally prioritised by key stakeholders to ensure the best use of available resources, maximum likelihood of research leading to uptake into policy and practice and relevance to the needs of the potential beneficiaries. Established approaches are complex and time-consuming, therefore not feasible in settings where prioritisation is uncommon and time is limited. Objectives: We developed and applied a simple, rapid research prioritisation approach (RAPID-RP) to elicit the views of stakeholders. Setting and participants: This was a collaboration between a multidisciplinary group of UK academics, the International Primary Care Respiratory Group (IPCRG) and primary care respiratory researchers from four low- and middle-income countries (LMIC): Brazil, China, Georgia and North Macedonia. We identified 10 topics for research prioritisation through workshops involving 26 topic, methods and local context experts, and considering the programme remit, to develop, adapt and evaluate culturally appropriate community and behavioural approaches for the prevention, early identification and management of COPD in primary care. Design and methods: In each setting, local research teams convened stakeholder groups of patients, clinicians, managers / policy makers and researchers. Each group briefly discussed the ten potential research study topics. Discussions were facilitated using short vignettes for each topic, and participants encouraged to consider importance, feasibility and equity. Individual participants rated each study on a 3-point traffic light scale, then ranked them following a facilitated discussion on what drove the ratings. The research team rated then ranked each study considering three further criteria (international novelty, potential for future funding and capacity building on a 5-point scale). Within each group, ranks were summed to create a final rank order which guided our research programme and provided insight for future projects. Results: In each country, 4-8 members attended each stakeholder group, The engagement process was completed in less than four hours and feedback was very positive, especially from patients who valued the opportunity to contribute to research decision-making about their own condition. Ranking varied to some extent between groups and settings, but there was consistency around topics that were prioritised among the top 5 in all groups (identifying efficient COPD screening test strategies, evaluations of lung age to aid smoking cessation, feasibility of locally-adapted pulmonary rehabilitation, clinical education for primary care staff) and study topics that consistently ranked low (use of e-cigarettes for smoking cessation, weight management to improve COPD symptoms and handwashing to reduce infections).Limitations: Despite attempts to maximise inclusivity and diversity, stakeholders were mainly limited geographically to the centres where researchers were based, potentially limiting generalisability of views across the countries. Facilitator styles varied and may have influenced some of the discussions and potentially the ranking.Conclusions: Despite some limitations, we demonstrated the feasibility and acceptability of the RAPID-RP stakeholder analysis for identifying locally relevant research priorities in LMIC settings.Future work: Further validation is needed for aspects of the process. We have identified some useful lessons from our evaluation of the process, to facilitate future use of this approach.<br/

Feasibility of a pulmonary rehabilitation programme for patients with symptomatic chronic obstructive pulmonary disease in Georgia:a single site, randomized controlled trial from the Breathe Well Group

OBJECTIVES: To assess the feasibility of delivering a culturally tailored pulmonary rehabilitation (PR) programme and conducting a definitive randomised controlled trial (RCT). DESIGN: A two-arm, randomised feasibility trial with a mixed-methods process evaluation. SETTING: Secondary care setting in Georgia, Europe. PARTICIPANTS: People with symptomatic spirometry-confirmed chronic obstructive pulmonary disease recruited from primary and secondary care. INTERVENTIONS: Participants were randomised in a 1:1 ratio to a control group or intervention comprising 16 twice-weekly group PR sessions tailored to the Georgian setting. PRIMARY AND SECONDARY OUTCOME MEASURES: Feasibility of the intervention and RCT were assessed according to: study recruitment, consent and follow-up, intervention fidelity, adherence and acceptability, using questionnaires and measurements at baseline, programme end and 6 months, and through qualitative interviews. RESULTS: The study recruited 60 participants (as planned): 54 (90%) were male, 10 (17%) had a forced expiratory volume in 1 second of ≤50% predicted. The mean MRC Dyspnoea Score was 3.3 (SD 0.5), and mean St George’s Respiratory Questionnaire (SGRQ) 50.9 (SD 17.6). The rehabilitation specialists delivered the PR with fidelity. Thirteen (43.0%) participants attended at least 75% of the 16 planned sessions. Participants and rehabilitation specialists in the qualitative interviews reported that the programme was acceptable, but dropout rates were high in participants who lived outside Tbilisi and had to travel large distances. Outcome data were collected on 63.3% participants at 8 weeks and 88.0% participants at 6 months. Mean change in SGRQ total was −24.9 (95% CI −40.3 to –9.6) at programme end and −4.4 (95% CI −12.3 to 3.4) at 6 months follow-up for the intervention group and −0.5 (95% CI −8.1 to 7.0) and −8.1 (95% CI −16.5 to 0.3) for the usual care group at programme end and 6 months, respectively. CONCLUSIONS: It was feasible to deliver the tailored PR intervention. Approaches to improve uptake and adherence warrant further research. TRIAL REGISTRATION NUMBER: ISRCTN16184185

Strengthening clinician-researchers’ communication and knowledge translation skills:An innovative game model from the Breathe Well group

Communication is a core component of a clinician’s role; however, when clinicians conduct research, communicating the emerging findings and recommendations to different types of stakeholders can be unfamiliar territory. Communicating research to advocate for change can be even more challenging. Clinician researchers seeking to be agents for change need to conceive and craft specific, evidence-based messages and communicate these effectively to different stakeholders to negotiate action. As part of a global health research programme, we developed and tested a novel game-based model to strengthen the communication skills of clinician researchers, from four countries, for improving services for chronic obstructive pulmonary disease. This model focused on communication with three key stakeholder groups for knowledge translation: Patients/carers, healthcare providers and policy makers/healthcare managers. Delivered through a series of facilitated, online meetings, this model consisted of two parts: developing and rehearsing advocacy messages with coaching support, and then testing them with a panel of three representative stakeholders, and an audience of fellow researchers. All the country teams reported increased confidence in crafting advocacy messages for specific stakeholders and have applied lessons learned from the model. Delivering this model within a global health research programme requires mentoring, time, commitment, resources and translation support to address language barriers. It offers an exemplar to build the communication skills of clinician and non-clinician researchers so that they can go beyond dissemination towards translation of evidence into policy and practice