Understanding lung health beliefs in low-resource settings

Although lung disease burden is high and need for improved health outcomes is great in low-resource settings, successful adoption of implementation research strategies has often been challenging.¹ Two common preventable risk factors for chronic respiratory diseases (CRDs) are tobacco use and household air pollution (HAP). However, many middle- and low-income countries continue to face rising smoking epidemics despite increasing legislation of World Health Organization tobacco control policy recommendations.^2,3 Similarly, acceptance rates of improved cookstoves that generate less smoke have been generally poor in many low-resource contexts.⁴ While this lack of consistent success is likely multifactorial, understanding local health beliefs and practices remains central to the effective introduction and long-term adoption of any health intervention.

Through an observational mixed-method study reported in the Lancet Global Health, Brakema et al examined health beliefs and behaviors related to CRDs in six low-resource settings in Uganda, Vietnam, Kyrgyzstan, and Greece. The research team interacted with community members, healthcare professionals and key informants using qualitative methods (interviews, focus groups, household and provider consultation observations) combined with quantitative surveys. Three main themes were identified.

The first theme involved perceived disease identity. Community members frequently attributed chronic respiratory symptoms to acute communicable diseases, predominantly tuberculosis. In fact, most community members had not heard of the term “COPD” and did not understand the chronic and noncommunicable nature of asthma and chronic bronchitis. Although healthcare professionals were much more familiar with terms such as COPD, asthma, and chronic bronchitis, 23.3% still attributed chronic respiratory symptoms to acute infections. Additionally, most healthcare providers mainly focused on the acute manifestations of these diseases and felt that chronic asthma required treatment in referral hospitals. The second theme centered around beliefs regarding the causes of CRDs. Tobacco smoking topped this list which also included HAP, witchcraft in Uganda, the evil-eye in Kyrgyzstan, a hot-cold disbalance in Vietnam, and humidity in Greece. The third theme focused on norms and social structures. Most smokers in this study were men and smoking behavior was associated with masculinity in Vietnam and Kyrgyzstan. Other deeply rooted traditions and values, including the indoor coal-burning ritual for post-partum women in Vietnam, the focus on self-reliance in Kyrgyzstan and outsider distrust within a Roma camp in Greece, were also found to affect health-related behaviors in these settings.

This is a well-conducted, thorough, and impactful study that not only explains why some CRD-related implementation strategies have previously failed in low-resource settings, but it also provides a roadmap for the successful introduction of future implementation strategies. Comprehensive initiatives to raise awareness and improve health literacy around CRDs and other noncommunicable diseases (NCDs) are sorely needed, especially given the increasingly growing burden of NCDs in low- and middle-income countries. For example, the age-standardized disability-adjusted life-year rate due to NCDs in sub-Saharan Africa now nearly equals that of communicable, maternal, neonatal, and nutritional diseases combined.⁵ Therefore, while acute respiratory infections remain an important cause of morbidity and mortality in low-resource contexts, the silent epidemic of CRDs should not be underestimated.⁶

Local health beliefs and values are not necessarily always at odds with proposed health interventions and can, in fact, be leveraged to facilitate their adoption. This strategy has already proved to be successful as demonstrated by two recent FRESH AIR implementation studies. In the first, extensively raising awareness about the harms of HAP exposure, especially in children whose health was deemed very important, led to a high acceptance of improved cookstoves and heaters in Uganda, Vietnam and Kyrgyzstan.⁷ In the second, the existing ‘filotimo’ norm of not letting others down was leveraged in rural Greece to motivate those enrolled in a pulmonary rehabilitation program to exercise as a group.⁸

The factors behind incomplete medical knowledge of CRDs among healthcare providers were not systematically examined in this study. A recent systematic review of COPD guidelines in low- and middle-income countries revealed significant gaps in their development, content, context, and quality.⁹ The nature and extent of gaps affecting CRD content in local medical curricula are unknown and warrant further study to identify areas of improvement. Although the focus has been on asthma and COPD given their high prevalence, other CRDs such as interstitial and occupational lung diseases should not be forgotten given their rising incidence and impact in low-resource communities. In sub-Saharan Africa, disability-adjusted life-years due to pneumoconiosis and interstitial lung diseases increased by 41.9% and 77.7%, respectively, between 1990 and 2017.⁵

There is an urgent need to prevent and reduce the burden of CRDs in low- and middle-income countries.¹⁰ Only through close collaboration of the public, healthcare professionals, public health officials, policy makers and the international community can the best outcomes be achieved in these low-resource settings with regards to reducing the risk of CRD implementation research failure, securing an adequate allocation of resources, and most importantly, improving the lung health of affected communities.