Introduction
Globally, chronic obstructive pulmonary disease (COPD) has an increasing prevalence and constitutes a substantial socioeconomic burden [1]. In 2017, above 3% of disability-adjusted life years and 3.2 million deaths were ascribed to COPD worldwide [2]. A recently published meta-analysis estimated a 12% global prevalence of COPD [3]. More than 90% of COPD-related deaths occur in low-and middle-income countries (LMICs) [4]. COPD is the most prevalent non-communicable diseases (NCDs) in Nepal, with a 12% prevalence in adults [5]. In 2016, nearly one million Nepalese people were suffering from COPD, twice as many as in 1990 [6]. The higher burden of COPD in Nepal can be attributed to a high rate of tobacco smoking [7], substantial use of biomass fuel for cooking [8], poor outdoor air quality [9], exposure to second-hand smoking [8], and a demographic development with an aging population [10].
One of the major challenges in COPD prevention and management in Nepal’s already weakened health system, is the shortage of COPD specialists. The number of practicing pulmonologists in Nepal is relatively low, and most are based in the capital city Kathmandu or other big cities. Lack of proper diagnostics, treatment, and medications at peripheral health centers in combination with a low level of health literacy and awareness of the disease in the population constitute important challenges facing the increasing burden of COPD in Nepal [11–13]. COPD diagnosis is mostly limited to symptomatic assessment without objective confirmation by spirometry [12], potentially leading to underdiagnosis and misdiagnosis.
In a scenario with health workforce shortage, the shifting of tasks such as screening, education, referral, and follow-up to non-physicians such as community health workers (CHWs) can be an effective way to ensure the delivery of health care services [14]. The World Health Organization recommends optimizing community-based programs involving CHWs to prevent and manage NCDs, including COPD [15]. It is widely recognized that CHWs play an important role in a wide range of health behavior improvement and health outcome initiatives [16, 17]. Recently, CHW-led interventions have shown positive results in preventing and managing NCDs, including type 2 diabetes and hypertension [18]. Training programs for CHWs in monitoring and care of COPD patients in a rural part of India [19], and educational interventions for CHWs to increase awareness on COPD at a community level in Uganda [20] are some of the promising examples of CHWs’ engagement in community-based management of COPD in LMICs.
A network of CHWs, Female Community Health Volunteers (FCHVs), has been operating within the Nepalese health system for the last three decades [21]. FCHVs are local women selected by mothers’ groups in the communities receiving a short 18 days training. They serve as a bridge between the community and the health system, increasing health service utilization, promoting healthy behavior, and raising health awareness in the community [22]. Recent studies have shown promising results of the work of FCHVs in type 2 diabetes and hypertension management in Nepal [23, 24]. However, FCHVs’ involvement in COPD prevention and management has not yet been explored.
A research project entitled ’Community-based management of COPD in Nepal—a cluster-randomized controlled trial (COBIN-P)’ has been implemented in a collaboration between Aarhus University in Denmark and Nepal Development Society in a semi-urban area of Pokhara Metropolitan city of western Nepal [25]. This ongoing study aims to assess the effectiveness of an FCHV-led intervention to prevent COPD and improve disease management among adults with COPD. This study reports on the development and evaluation of the feasibility and preliminary effectiveness of a training program to strengthen and extend the knowledge of FCHVs in an intervention to prevent and manage COPD at community level.
Methods
Study setting and data collection
This study is part of the COBIN-P project. This two-arm cluster randomized controlled trial is ongoing in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) of Western Nepal [25]. As a part of the study intervention, FCHVs were trained to raise awareness of prevention and management of COPD at the community level through household visits. FCHVs’ knowledge of COPD was assessed before and after the training program. Eight informants were recruited by convenience sampling to reach data saturation and eight in-depth interviews provided data on FCHVs’ feedback on the training program. The training program and data collection took place from December 2019 to February 2020. Similarly, prior to developing and designing the training program, eight stakeholders from the community (three FCHVs, two health assistants, one medical officer) and two health education experts were purposively selected.
Developing a training program and educational materials for FCHVs
The study team developed the training program, including training curriculum and tools, based on an extensive literature review of similar CHWs-led interventions on the management of COPD and other NCDs. The team reviewed the health education materials previously used in tobacco and tuberculosis control, hypertension, and diabetes management programs in Nepal [26, 27]. The curriculum was developed by triangulating with domain experts, National Health Education and Information Center (NHEICC) professional staff, district health administrators, physicians, and FCHVs. As some of the community people and FCHVs were illiterate, locally appropriate tools were also developed, including pictorial flip charts and brochures for screening and management of COPD (S1 Appendix).
Based on a literature review, the training program was designed to provide FCHVs with knowledge regarding COPD risk factors, signs, and symptoms, management of COPD via screening, basic breathing techniques, stamina, endurance-building exercises, and knowledge about healthy lifestyle and medication adherence. Likewise, FCHVs were also trained to use educational materials during their home visits, and to identify and refer patients to the nearest health facility, and properly maintain recording and reporting forms. Every session was followed by skills-building sessions. Training was guided by a facilitator’s manual, ’Community Based Prevention and Management of COPD in Nepal: Female Community Health Volunteer’s Training Facilitator Guide’. The facilitators’ guide was developed to assist facilitators in being familiar with the module contents, session objectives, and delivery methods. The training materials, including the facilitator guide, were developed following procedures adopted for other COBIN studies on diabetes and hypertension [26, 27], and Engage-Tuberculosis Training of Community Health Workers and Community Volunteers: Facilitator’s Guide [28]. Experts were consulted for suggestions to be incorporated into the training program. Pilot testing of the training matrieals and program was performed, and adaptations were made. The FCHVs received training for 30 hours during a period of six days (S1 Table).
Training of FCHVs
There were 123 FCHVs working in the study area. Fifty-seven FCHVs from the randomly assigned seven intervention clusters were invited for a one day orientation and assessment session. During the first day of training, FCHVs were informed about the COBIN-P project and introduced to COPD. FCHVs were then assessed for the minimum requirements of reading, writing, motivation, and availability to attend the next five days of training and the one-year intervention period. A total of 23 FCHVs fulfilled the requirements and were enrolled for the next five days of training. One FCHV dropped out of the training after two days due to personal reasons. The training program was delivered by the principal investigator (TBA), a medical officer from the Ministry of Health and Population who was also a certified trainer of World Health Organization package of essential NCDs, a consultant pulmonologist, and two health staffs from the local organization Nepal Development Society with previous experience in NCDs-related training. The training sessions were conducted in the local language (Nepali) using PowerPoint presentations, videos, demonstrations, and group exercises. The six-day FCHVs training package consisted of seven units and 16 lessons summarized in S1 Table.
Evaluation
The training program was evaluated using both quantitative and qualitative methods. FCHVs completed a short questionnaire in the local language measuring their degree of COPD knowledge before and after training. The knowledge assessment questionnaire (S2 Appendix and S3 Appendix) was adapted from previous studies [20, 29]. Participants completed the questionnaire in strict confidentiality. Similarly, the skills of FCHVs were assessed on teaching breathing exercises, stamina and endurance building exercise, skills on using a flip chart, and COPD status assessment guide during and at the last day of the training using a skill assessment evaluation form. All FCHVs performed the required tasks during the assessments. Also, the field supervisor regularly monitored and supervised the FCHVs throughout the phase of trial implementation using an evaluation and supervision form (S4 Appendix). We conducted in-depth interviews with three FCHVs, two health assistants and one medical doctor, at the primary health care centers in the study area while designing the training package and educational material for the intervention. Through these pre-training interviews, we explored the health-seeking behavior for COPD, provision of health service delivery for COPD, and the importance and components of the community-based program to prevent and manage COPD. One month after the training, eight FCHVs were interviewed to assess their experiences with the training, obstacles, and challenges in delivering the intervention in the community using topic guide for the interview (S5 Appendix and S6 Appendix). Two trained researchers (TBA and AS) with a degree in public health and previous experiences in facilitating in-depth interviews conducted the interviews.
Data analysis
Demographic characteristics of FCHVs were summarized using means and percentages. Each knowledge statement was recorded as a dummy variable, scoring 1 for correct and 0 for incorrect responses. The proportion of participants with correct responses for every statement on the questionnaires was determined and compared before and after using the McNemar test. The overall score was calculated by adding the dummy score 1 and 0 before and after the training. The overall change in knowledge score before and after the training was assessed using the Wilcoxon signed-rank test. All statistical tests were two-sided at alpha = 0.05. Data were entered in Epi Data version 4.0 (The EpiData Association, Odense, Denmark) and analyzed using STATA version 15.1 (StataCorp. Texas, USA). Data are presented as mean ± standard deviation (SD). FCHVs providing verbal consent and permission to audio-record the interviews were included in the qualitative study. The interviews were audio-recorded in the local language, transcribed verbatim and later translated into English. A thematic analysis was conducted for transcripts from interviews [30]. It included the steps of iterative reading of interview transcripts, creating initial codes, arranging the codes, and generating a thematic map of the analysis. Two researchers (TBA and AS) analyzed the qualitative data independently, and consensus regarding the nature and coding of emerging themes was reached through discussion with other team members.
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the review board of the Nepal Health Research Council (Approval number: 30–2019), and written informed consent was obtained from all participants.
Discussion
In this study, we developed, implemented, and evaluated a first-of its kind, COPD prevention and management training program for FCHVs in Nepal. We found that following participation in this structured training program, FCHVs’ knowledge of COPD significantly (p<0.001) increased from a median knowledge score of 12 to 21 (total score = 24). Before the training, a relatively low number of FCHVs knew that smoking causes COPD and that avoiding biomass fuel smoke prevents the disease from worsening. Similarly, only three out of 22 FCHVs knew the importance of influenza and pneumonia vaccinations for patients with COPD. Overall, we observed a knowledge insufficiency in the fundamental domains of symptoms, risk factors, and treatment of COPD among FCHVs, which significantly improved after our training program.
One of the strengths of this FCHVs training was that the training was based on a comprehensive literature review, stakeholder meetings, utilization of existing nationally endorsed health promotion messages, and tailored to the community of the study area. The training was delivered through presentations, videos, role plays, demonstrations, and group exercises, as recommended by previous studies [19, 31]. All these elements increased the effectiveness of the training. We believe this training package with necessary community-specific modifications can be replicated in similar settings in other parts of Nepal. It must be considered that some FCHVs found that continuous training for six days was challenging to participants to comprehend all the new knowledge at once, although we incorporated fun games, local singing, and dancing in between sessions to engage participants and to give a sense of break so that the training was not overwhelming. The qualitative assessment of FCHVs showed motivation and interest among FCHVs in delivering the intervention in the community, and FCHVs perceived that the community was responsive. FCHVs became confident in using the status assessment guide and making referrals. In the context of Nepal, where the objective diagnosis of COPD in primary healthcare centers is very low, and COPD is largely undiagnosed in the community [12, 32], FCHVs can be trained in using short screening questionnaires to screen potential COPD cases in the community. Several short and simple COPD screening tools are being used elsewhere [33], which could be validated in Nepal for community-based screening of COPD by FCHVs.
A noteworthy finding from the qualitative assessment indicated that community-based COPD prevention and management would be challenging to implement and less effective unless local health facilities are strengthened in terms of diagnosis, management, and treatment. Therefore, along with community-based interventions, efforts should be made to strengthen the local health facility’s capacity to effectively diagnose and treat COPD at an affordable cost. So those potential COPD patients referred by CHWs from the community who otherwise would have been missed are identified early and treated appropriately. Also the strengthening of the health system’s readiness and response to CHWs referrals with proper diagnosis, treatment, and medication is needed to increase the trust and effectiveness of CHWs in the community [34].
Patient activation and empowerment for self-management are essential in managing COPD and improving quality of life [35]. In our study, FCHVs were confident in delivering home-based counseling on COPD and demonstrating breathing techniques, stamina and endurance building exercises, support on symptoms assessment, and bridging the gap to health services. A feasibility study conducted in the UK showed lay health workers being acceptable and supportive in uptake and completion of pulmonary rehabilitation in COPD [36]. This sheds light on the need for future research on FCHVs involvement in pulmonary rehabilitation for COPD in resource-limited settings like Nepal.
The widely discussed remuneration and overburdening of CHWs with multiple roles is a matter of concern and also revealed in our qualitative findings [34, 37]. The remuneration of CHWs is considered an essential factor for motivation [37]. In our research, we provided transportation costs as remuneration for their work following the government guidelines of FCHVs incentives. FCHVs also suggested that integrated training, i.e., training on diabetes, hypertension, and COPD could be important as number of households with multiple NCDs are increasing in the community. The integrated package of NCDs for CHWs routine work would eventually reduce the burden and empower FCHVs to help community people comprehensively, but further research and policy discourses on this aspect are needed.
This study presented the development and evaluation of a training program for implementing an FCHV-led model of COPD prevention and management in a community in Nepal. This study had some limitations. The relatively small sample size of trained FCHVs and conveniently selected participants could limit the generalizability of our findings. FCHVs received our training program well; however, this research was implemented by an organization with previous experience in implementing FCHV-led interventions in type 2 diabetes and hypertension management at the same study site [23, 38]. Therefore, FCHVs may have overstated the effect because they do not want to be impolite to the research team. Nevertheless, when triangulating with a knowledge questionnaire, our findings were confirmed. Also, we cannot exclude that FCHVs might face some challenges in counseling some male participants in the context of patriarchal societal norms. However, noting the three-decade well-accepted presence and experience of FCHVs working in the community might partially address this issue. Other COBIN interventions were also implemented mobilizing FCHVs, and they did not face this challenge. We expect there would not be cultural issues that FCHVs may face in their interaction with male COPD patients [23, 38]. Likewise, counseling is considered an important component of this training program, and FCHVs are well-trained in culturally appropriate counseling. Finally, the COPD knowledge questionnaire in this study was adapted from previous studies conducted in Uganda and Turkey [20, 29]; therefore, contextualization and validation of the COPD knowledge assessment questionnaire in Nepal seems necessary for future studies.
The current COPD-related national program and policies in Nepal do not address COPD in the community and do not provide adequate directions to minimize the potential public health impact [39]. Thus, despite these limitations, this study as the first of its kind in Nepal to develop a training program for FCHVs to prevent and manage COPD, opens a discourse for further research in mobilizing local health resources to strengthen community health system to combat COPD.