The study,“The situation of detecting and managing some common lung diseases at commune health stations in Thai Nguyen province and effectiveness of some intervention solutions”aims to a
Trang 1INTRODUCTION
Lung disease is a high morbidity and mortality disease worldwide Common lung diseases (CLDs) are acute pneumonia, tuberculosis (TB), bronchial asthma, chronic obstructive pulmonary disease (COPD), lung cancer Some common chronic lung diseases such as TB, bronchial asthma, COPD are the main cause of death in adults At present, TBremains a major health problemworldwide COPD isthe third leading cause of death The number of asthma infected and death tend to increase In Thai Nguyen, the prevention and control of CLDs is still limited, especially at the grassroots healthcare level Each year, TBincidence rate ranges from 45% -50% of the estimated infection sources in the community Patients with bronchial asthma andCOPD have not been timely diagnosed and most of them have not been properly treated managed, the leading cause is the weak capacity of commune health workers (CHWs)
The study,“The situation of detecting and managing some common lung diseases at commune health stations in Thai Nguyen province and effectiveness of some intervention solutions”aims to achieve following
Trang 2NEW CONTRIBUTIONS OF THE DISSERTATION 1.The dissertation was described the situation of detecting and managing some common lung diseases of commune health workers in Thai Nguyen province in 2013
Capacity of CHWsfor management of some CLDs was not good:
- The percentage of CHWsachieved standard requirements for disease asking was very low: ask about the patient's medical history; ask about past medical history 18.4%; ask about history of risk factor exposure 23.8%; ask about the medical history of patient's family 45.7% and ask about the patient’s epidemiology history 20.9%
- The percentage of CHWsachieved standard requirements for whole body and physical examination practice was very low: describe the mental state of patients 52.5%; describe skin, lips, mucous membrane47.2%, take temperature 40.8%, breath rate counting 27.7%; inspection 70.9%; palpation 25.9%; percussion 23.8%; only auscultation was 89.0%
- The percentage of CHWsachieved standard requirements for disease management was very low: announce the disease for patients 52.8%; patient instruction for continuous activities 51.8%; encouraged patients38.7%; write clearly recorded medical records15.6%, especially only 17.0% had instructed patients to have sputum for TB detection
2 Some related factors for detection and management of common lung diseases of CHWsin Thai Nguyen province
- The direct factors were as follow: the poor knowledge, attitude, management skills, counseling skills of CLDs of CHWs; CHWshave to undertake many tasks and due to poor prevention and control of lung diseases of people
- The indirect factors were as follow: poor facilities; medical examination equipment; lack of communication materials; poor planning of chronic lung disease detection at the commune health station (CHS); commune organizations
Trang 3had not yet participated in the prevention of lung diseases; the province and district surveillance was not good
3 Effectiveness of some solutions in improving the detection and management of some common lung diseases of CHWs in Thai Nguyen province after 2 years of intervention
- The enhanced training solutionto improve knowledge, attitudes and skills for CHWs on the management of CLDs in the intervention commune was very good Intervention effect on good knowledge was 223.8%, good attitude was 85.4% and good skills was 292.6%
- The enhanced communication solution for people with intervention effect on good knowledge 169.0%, good attitude 17.2% and good skills 94.5%
- The “Department of Chronic Lung Disease Management” model had rapidly increased results of the number of managed people with bronchial asthma, COPD, annually
- The "Green breathing club" model at the province level and 15 clubs
at the commune level were operated regularly, achieved positive effects for patients and community, had highly appreciated by patients
- The results of the CHWs had properly managedCLDs in two intervention districts was much higher than the two control districts
STRUCTURE OF DISSERTATION
The dissertation has 134 pages, excluding the appendix:
Introduction: 2 pages
Chapter 1 Literature review: 30 pages
Chapter 2 Subjects and methods: 30 pages
Chapter 3 Study results: 37 pages
Chapter 4 Discussions: 32 pages
Conclusions and recommendations: 3 pages
Trang 4The dissertation has 115 references, including 53 Vietnamese references and 62 English references The dissertation has 35 tables, 12 boxes, 08 charts, 02 pictures The appendix includes 9 appendices with 23
1.1.2 In Viet Nam
At CHS, more than 30% of people have health examination for symptoms such as coughing or difficult breathing These symptoms are manifestations of respiratory diseases, including TB, bronchial asthma, and COPD The majority of those patients were not got sputum tests to detect
TB by CHWs, but are often diagnosed with other lung diseases and most of them are prescribed antibiotics Thus, TB is usually overlooked; bronchial asthma and COPD are diagnosed late and not properly treated
1.2 Some related factors to the detection and management of CLDs
1.2.1 Direct factors
1.2.1.1 Human resources and professional qualifications
In human resources, besides the illogicality of number and structure, CHWs are rarely trained and retrained Therefore, knowledge gradually erodes There is rarely in training for new knowledge of detecting and managing CLDs (bronchial asthma, and COPD), greatly affecting the
Trang 5professional quality at CHS This is a not goodrelated factor to general medical examination and detection, management of CLDs
1.2.1.2 Counseling skill on prevention and control of some CLDs
CHWs are weak in counseling skills for many diseases, including CLDs Therefore, it is necessary to improve the capacity of CHWs in terms
of CLDs counseling skills This is also a not good related factor to general medical examination and treatment, detection and management and detection, management of CLDs
1.2.2 Indirect factor
1.2.2.1 Knowledge, attitude, practice of people on prevention and control of CLDs
Knowledge, attitude, practice (KAP) of people on prevention and control
of CLDs is an indirect factor that can well or badly affected on the detection and management results of CLDs of CHWs In Vietnam and,particularly, in Thai Nguyen, the lack of knowledge situationsabout CLDs is quite common, especially in mountainous and rural areas
1.2.2.2 Facilities, techniques, medical equipment
Theseare indirect factors affecting community health care According to
a survey by the Ministry of Health, the number of CHS had standard facilities and equipment accounts for only 9.8% These difficulties are indirectly related factors to general health care and the detection and management of CLDs of CHWs in particular
1.2.2.3 Counseling, health education and communicationfor the community
Lacking knowledge of CLDs such as TB, bronchial asthma and COPD will lead to late diagnosis, non-standard management, leading to more severe diseases, reduce the patients’ quality of life; TB will spread more in the community
Trang 61.3 The enhanced detection and management solutions forCLDs
1.3.1 General solution
WHO had been developed on the Directly Observed Treatment Short course (DOTS) strategy since the 1990s Since then, DOTS has been effectively applied around the world, especially in high TB burden countries, including Vietnam In 1997, WHO proposed the PAL strategy to increase the quality of CLDs management PAL was identified as a part of the new global TB program from 2006to 2015
1.3.2 The applicable solutions in Vietnam
- Continuing to well implement the DOTS strategy: From 1996, Vietnam began to implement the DOTS strategy Until 1998, DOTS strategy had been implemented nationwide and maintained to achieve good results Therefore, it is necessary to continue in well-implementing the DOTS strategy in the future
- Implementing the PAL strategy: Data from countries show that PAL is very effective in preventing lung diseases PAL raises the awareness of the community about the symptoms of respiratory diseases, increases the professional qualification of the CHWs, reduce referrals to avoid overcrowding, reduce the treatment cost due to earlystandard detection and management Especially, PAL significantly increases the rate of TBdetection Therefore, in the upcoming time, Vietnam needs to consider and evaluate the PAL pilot results for nationwide deployment
Chapter 2 SUBJECTS AND METHODS
2.1 Study subjects
CHWs, the TBcontrolprogram staffs at district health center andprovince level, village health workers, primary health care committee staffs, village
Trang 7leaders; commune women staff, CLDs patients, CLD reports in the
commune
CHWs are directly received, examine and manage for people with CLDs Village health workers support CHWs in CLDs prevention People and CLD patients often meet CHWs with health examination, treatment, counseling, health communication and education Interviewed subjects were leaders of CHS, district health centers, primary health care committee, and the provincial TBcontrolprogram.Selected subjects for focus group discussions were district TBcontrol program secretary, district health center staff, CHS leaders, village leaders, village health workers, commune women staff, CLDs people
2.2 Study setting, time, facilities and materials
+ Two midland districts: Pho Yen and Phu Binh
- Select all communes in those 6 district units
2.2.2 Study time:The study was conducted from March 2013 to August
2019(Data collected from May 2013 to November 2016)
2.2.3 Study facilities and materials
+ The questionnaire form for interviewing CHWs,
+ Checklist skills for examination and managementCLDs of CHWs, + Checklist skills for communication and health education of CLDs of CHWs,
+ The questionnaire form about KAP for people,
Trang 8+ A guideline for group discussion of district healthcenters staffs and CHWs,
+ A guideline for group discussion of primary health care committee staffs and village leaders,
+ A guideline for group discussion of commune women staffs and village health workers,
+ A guideline for group discussion of lung and TB patients;
+ Secondary data collection form
+ Training material on practical management skills about CLDs, + Training material on communication and health education skill about CLDs
2.3 Methodology
2.3.1 Methodology and study design
The descriptive and intervention study methods was conducted, combined both quantitative and qualitative study
- Using 2 study design:
+ Cross-sectional descriptive
+ Community interventionwith controlled before-and-after study
- The study was divided into 2 stages:
+ Stage 1:
FromMay 2013 toJune 30th2013, a cross-sectional descriptive study was conducted to survey the CLDsdetection and management of CHWs in communes in all province and describe factors related to CLDs management capacity of CHWs
+ Stage 2:
From July 1st2013 toJune 30th2015,community intervention with controlled before-and-after study was conducted to evaluate the
Trang 9effectiveness of some solutions in improving the detection and management
of CLDs at CHS after 2 years of intervention
FromJuly 2015 to the end ofDecember 2015 was the time of intervention assessment in Dong Hy and Pho Yen districts and follow up assessment in Phu Luong and Phu Binh districts (control districts)
FromJanuary 2016, aggregate, analyze data, write reports
2.3.2 Sample size and study sampling
2.3.2.1 Study sampling for quantitative study
* Sampling method for descriptive study
- Sampling method for CHWs evaluation:
Sampling technique: Select CHWswhich is participated in medical examination and treatment (doctors, assistant doctors) Make a list of all CHWs which is participated in medical examination
Standard to exclude as follows:
+ CHWs did not cooperate with the research;
+ CHWsparticipatedin examination bytraditional medicine
In fact, the number of qualified CHWs in 6 districts of province was 282 people The sampling technique was total sample
- KAP study sample technique in people:
Sample size: Apply a formula to calculate population with specified absolute precision:
d p
Trang 10According the formula:n = 385
To prevent errors due to study subjects giving up during the study, increase the sample size by 5% and round up to 400 people
+ : statistical significance level, as 0.05
+ : the probability of a type II mistake, as0.1
Samplepower is 90%
+ Z2 (): based on andcorresponding table, gets10.5
According to the formula:n = 64
To prevent errors due to study subject giving up during the study, increase the sample size to 70 people In fact, 78 eligible CHWs was selected to the study (the ratio 1:1)
- Sampling technique:random sampling method
2.3.2.2 Sampling for qualitative study
Qualitative study was conducted in 4 study districts:
Trang 11- Each district has 1 group discussion between district TBcontrol program secretary, district center for disease control staff, CHS leaders, CHWs in charge of TB control program
- Each district randomly select 1 commune for group discussion
Activity 2:
+ Improve TB knowledge for people and community
+ Support communication materials about lung disease and TB for CHS + Enhanced the inspection and surveillance activities of the preventing and controllingTB and lung diseases at the province and district level to communes
+ Organizethe monthly meeting between province, district and commune level on the practice of CLDs management and TB detection(integration)
Activity 3:
Building up "Green breathing club": develop 15 clubs in communes of two intervention districts Participants of the club are patients, patients' relatives, CHWs and volunteers
- At Thai Nguyen Tuberculosis and Lung hospital:
+ Building one room for chronic lung disease management (CMU)
+ Building a "Green breathing club"
- Group discussion in districts before and after the intervention:
+ Group discussion with district health centerstaffs, CHS leaders (15 people)
Trang 12+ Group discussion with leaders of primary health care committee, village leaders (15 people)
+ Group discussions with village health workers and commune women staffs (15 people)
+ Group discussion with TB and lung diseases (15 people)
* Content and evaluation methods:
- Evaluation content: Compare changes:
+ KASof CHWs on detection, management, counseling, health education and communication about CLDs prevention and control
+ KAP people in CLDs prevention and control,
+ Results of activities on CLDs detection and management, results of pulmonary TBdetection, bronchial asthma, COPD in intervention and control districts
+ Assessment the activities of "Green breathing" clubs
+ Assessment the result activities of Chronic Lung Disease Management (CMU) at provincial Tuberculosis and Lung hospital
- Evaluation method: Compare results:
+ Activity indicators at pre- and post-intervention periods in the intervention districts; before-after 2 years in the control districts (same period of intervention in the intervention district);
+ Activity indicators between intervention districts and control districts
at 2 period times before and after the intervention;
- Evaluating the intervention results based on efficiency index (EI) and Intervention effect (IE):
+ Efficiency index (EI) % =
Of that: p1 is the rate before and p2 is the rate after intervention
+ Intervention effect(IE) = EIintervention- EIcontrol
1001
21
P P P
Trang 13* Survey secondary data on the detection and management of CLDs at all CHSof the studied districts
* Data analysis methods
- Quantitative data were analyzed on SPSS 20.0 software
- Qualitative data: analysed the audio and video tapes, records
The study was conducted after get ethic approval from the ethic council
of Thai Nguyen University of Medicine and Pharmacy
Chapter 3 STUDY RESULTS 3.1 The situation of detecting and managing some common lung diseases of CHWs in Thai Nguyen province in 2013
3.1.2 The situation of skills of asking, examining and managing CLDs of CHWs in Thai Nguyen province in 2013
Writeclearlyand completely medical record 44 15.6 Guiding patients to take sputum for TB testing 48 17.0