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Community-based management of COPD in Nepal
Correspondence
Community-based management of COPD in Nepal
Wikimedia/Dhilung Kirat
Estimates1–3 of the prevalence of COPD in Nepal range from 23–43%. Use of biomass fuels, cigarette smoking, and outdoor air pollution are the three most common risk factors for COPD in the country.1 Prevalence appears to be higher among Nepali women than men, possibly due to longer periods of time spent indoors cooking or doing household chores.3 To combat COPD in Nepal, more focus should be laid on prevention and early detection. Efforts to reduce exposure to risk factors, including advice for smoking cessation and limiting or managing the use of biomass fuels for cooking and domestic heating, could prove important. Early detection will help in timely medical intervention through oral and inhalation treatment available at secondary hospitals. One approach is to mobilise community health workers in the fight against COPD. The female community health volunteer (FCHV) programme has existed in Nepal since 1988, and the country boasts more
e6
than 50 000 FCHVs. The programme comprises women selected locally and trained to provide immunisation, Vitamin A supplementation, and maternal and child health services. A qualitative study indicated that FCHVs were willing to use their knowledge and skills to help control non-communicable diseases (NCDs), in addition to infectious diseases and maternal and child health problems.4 Brief and simplified questionnaires could be used by FCHVs to screen individuals likely to have airflow obstruction. Questionnaires such as the COPD population screener5 and the Lung Function Questionnaire6 are available but have not been validated in a Nepali context. We propose that such tools be validated in Nepal and administered by FCHVs at the community level. In addition to their usual roles of health education and counselling, FCHVs could raise awareness about the harms of cigarette smoking and traditional cooking stoves, ways to access government subsidies for setting up biogas and improved stoves, and the precautionary approaches of avoiding dust and smoke exposure. Portable spirometers that can be connected to mobile phone applications have been made available, mostly to be used independently by individuals. Spirometry is not yet widely available in Nepal and these portable devices could therefore prove valuable by complementing prespirometric questionnaires by FCHVs. Once FCHVs identify those at risk, they can refer them to their local health facility, where trained health workers can complete spirometric assessments of airway obstruction, which may then be followed-up with counselling, management, or referral.
Mobilisation of community health volunteers in COPD screening coupled with the adoption of portable spirometers could prove valuable in Nepal as a community-based approach of COPD management. This will also align with the government’s Multisectoral Action Plan on NCDs (2014–20) which aims to strengthen the primary healthcare system’s ability to handle COPD through promotion of essential medical technology and expansion of its current free essential medicines list, and to explore the role of FCHVs in NCD prevention. A feasibility study to understand the issues of potential challenges and cost could help in assessing the viability of such intervention. We declare no competing interests.
*Rupesh Gautam, Dinesh Neupane, Arjun Karki, Per Kallestrup [email protected] Department of Public Health, Aarhus University, Aarhus, Denmark (RG, DN, PK); and Grande International Hospital, Kathmandu, Nepal (AK) 1
2
3
4
5
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Bhandari GP, Angdembe MR, Dhimal M, Neupane S, Bhusal C. State of non-communicable diseases in Nepal. BMC Pub Health 2014; 14: 23. Pokharel BR, Humagain S, Pant P, Gurung R, Koju R, Bedi TRS. Spectrum of diseases in a medical ward of a teaching hospital in a developing country. J Coll Med Sci-Nepal 2012; 8: 5. Bhandari R, Sharma R. Epidemiology of chronic obstructive pulmonary disease: a descriptive study in the mid-western region of Nepal. Int J Chron Obstruct Pulmon Dis 2012; 7: 253–57. Neupane D, McLachlan CS, Gautam R, et al. Literacy and motivation for the prevention and control of hypertension among female community health volunteers: a qualitative study from Nepal. Glob Health Action 2015; 8: 10.3402. Martinez FJ, Raczek AE, Seifer FD, et al. Development and initial validation of a self-scored COPD population screener questionnaire (COPD-PS) COPD 2008; 5: 85–95. Spyratos D, Chloros D, Haidich A-B, et al. Comparison among three screening questionnaires for COPD diagnosis in the primary care. Eur Respir J 2013; 42 (suppl 57): P266.
www.thelancet.com/respiratory Vol 5 January 2017
Community-based management of COPD in Nepal
Wikimedia/Dhilung Kirat
Estimates1–3 of the prevalence of COPD in Nepal range from 23–43%. Use of biomass fuels, cigarette smoking, and outdoor air pollution are the three most common risk factors for COPD in the country.1 Prevalence appears to be higher among Nepali women than men, possibly due to longer periods of time spent indoors cooking or doing household chores.3 To combat COPD in Nepal, more focus should be laid on prevention and early detection. Efforts to reduce exposure to risk factors, including advice for smoking cessation and limiting or managing the use of biomass fuels for cooking and domestic heating, could prove important. Early detection will help in timely medical intervention through oral and inhalation treatment available at secondary hospitals. One approach is to mobilise community health workers in the fight against COPD. The female community health volunteer (FCHV) programme has existed in Nepal since 1988, and the country boasts more
e6
than 50 000 FCHVs. The programme comprises women selected locally and trained to provide immunisation, Vitamin A supplementation, and maternal and child health services. A qualitative study indicated that FCHVs were willing to use their knowledge and skills to help control non-communicable diseases (NCDs), in addition to infectious diseases and maternal and child health problems.4 Brief and simplified questionnaires could be used by FCHVs to screen individuals likely to have airflow obstruction. Questionnaires such as the COPD population screener5 and the Lung Function Questionnaire6 are available but have not been validated in a Nepali context. We propose that such tools be validated in Nepal and administered by FCHVs at the community level. In addition to their usual roles of health education and counselling, FCHVs could raise awareness about the harms of cigarette smoking and traditional cooking stoves, ways to access government subsidies for setting up biogas and improved stoves, and the precautionary approaches of avoiding dust and smoke exposure. Portable spirometers that can be connected to mobile phone applications have been made available, mostly to be used independently by individuals. Spirometry is not yet widely available in Nepal and these portable devices could therefore prove valuable by complementing prespirometric questionnaires by FCHVs. Once FCHVs identify those at risk, they can refer them to their local health facility, where trained health workers can complete spirometric assessments of airway obstruction, which may then be followed-up with counselling, management, or referral.
Mobilisation of community health volunteers in COPD screening coupled with the adoption of portable spirometers could prove valuable in Nepal as a community-based approach of COPD management. This will also align with the government’s Multisectoral Action Plan on NCDs (2014–20) which aims to strengthen the primary healthcare system’s ability to handle COPD through promotion of essential medical technology and expansion of its current free essential medicines list, and to explore the role of FCHVs in NCD prevention. A feasibility study to understand the issues of potential challenges and cost could help in assessing the viability of such intervention. We declare no competing interests.
*Rupesh Gautam, Dinesh Neupane, Arjun Karki, Per Kallestrup [email protected] Department of Public Health, Aarhus University, Aarhus, Denmark (RG, DN, PK); and Grande International Hospital, Kathmandu, Nepal (AK) 1
2
3
4
5
6
Bhandari GP, Angdembe MR, Dhimal M, Neupane S, Bhusal C. State of non-communicable diseases in Nepal. BMC Pub Health 2014; 14: 23. Pokharel BR, Humagain S, Pant P, Gurung R, Koju R, Bedi TRS. Spectrum of diseases in a medical ward of a teaching hospital in a developing country. J Coll Med Sci-Nepal 2012; 8: 5. Bhandari R, Sharma R. Epidemiology of chronic obstructive pulmonary disease: a descriptive study in the mid-western region of Nepal. Int J Chron Obstruct Pulmon Dis 2012; 7: 253–57. Neupane D, McLachlan CS, Gautam R, et al. Literacy and motivation for the prevention and control of hypertension among female community health volunteers: a qualitative study from Nepal. Glob Health Action 2015; 8: 10.3402. Martinez FJ, Raczek AE, Seifer FD, et al. Development and initial validation of a self-scored COPD population screener questionnaire (COPD-PS) COPD 2008; 5: 85–95. Spyratos D, Chloros D, Haidich A-B, et al. Comparison among three screening questionnaires for COPD diagnosis in the primary care. Eur Respir J 2013; 42 (suppl 57): P266.
www.thelancet.com/respiratory Vol 5 January 2017