Complex Interventions to Address Chronic Respiratory Diseases and Tobacco Smoking in a Lower-Middle Income Setting

Abstract

Chronic respiratory disease (CRD), including chronic obstructive pulmonary disease (COPD), asthma, and less common respiratory diseases, is one of the four major noncommunicable diseases worldwide. Tobacco smoking is a major, avoidable risk factor for CRD. In low- and middle-income countries, there are important barriers preventing people affected by CRD from gaining access to effective, evidence-based prevention and disease management. In Vietnam, little is known about the gap between evidence-based practice and actual clinical management for CRD and cigarette smoking. This thesis aims to assess the current practice for CRD and tobacco smoking in the Vietnamese healthcare system and to evaluate the feasibility of two interventions to reduce the burden of CRD and tobacco smoking. The first part of the thesis includes two cross-sectional studies conducted at all four levels of healthcare facilities in Vietnam. In the first study, I used a syndromic approach to assess patients visiting healthcare facilities due to respiratory symptoms. The findings suggested that COPD and asthma were often misdiagnosed and more than half of patients with the diseases did not receive maintenance inhaled medicines for airways disease. In the second study, we found a high prevalence of current smoking among male patients seeking healthcare. The majority of those who attempted to quit had never used any evidence-based method to help them quit. The second part of the thesis reports pilot studies for two trials that were conducted in three rural district hospitals in Hanoi. The first trial assessed the feasibility of a novel stepped approach to treatment of patients with undifferentiated CRD (asthma and/or COPD) using inhaled budesonide-formoterol. Our data collected over 12 months follow-up period suggested that this intervention is feasible in a rural setting in Vietnam. The second trial focused on tobacco smoking and the interventions included the implementation of smoke-free hospital policy, brief advice from doctors, and follow-up counselling phone calls and text messaging. We found a high rate of self-reported smoking cessation. However, many of the participants did not consent to biochemical verification of their quit status, limiting the interpretation of the trial. Finally, I conducted a process evaluation to assess various aspects of implementing the intervention for CRD that may affect patients’ outcomes. The process evaluation shows barriers and challenges to implementing the components of the intervention, such as insufficient inhaler education from pharmacists and underutilisation of management plan by patients. The findings from this process evaluation will help to improve the implementation of interventions for COPD and asthma in Vietnam.