Thực trạng phát hiện, xử trí một số bệnh phổi thường gặp tại trạm y tế xã của tỉnh thái nguyên và hiệu quả một số giải pháp can thiệp tt tiếng anh

1 INTRODUCTION 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 objectives: To describethe situation of detecting and managing some common lung diseases of commune health workersin Thai Nguyen province in 2013 To analysis some factors related todetect andmanagesome common lung diseases of commune health workersin Thai Nguyen province To evaluate the effectiveness some solutions in improving the detection and management of some common lung diseases of commune health workersin Thai Nguyen province after years of intervention NEW 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 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 had not yet participated in the prevention of lung diseases; the province and district surveillance was not good Effectiveness of some solutions in improving the detection and management of some common lung diseases of CHWs in Thai Nguyen province after 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: pages Chapter Literature review: 30 pages Chapter Subjects and methods: 30 pages Chapter Study results: 37 pages Chapter Discussions: 32 pages Conclusions and recommendations: pages The 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 appendices with 23 pages Chapter LITERATURE REVIEW 1.1 The situation of detecting and managing CLDs 1.1.1 In the world Since 1997, the World Health Organization (WHO) haddeveloped“Practical Approach to Lung Health - PAL” strategy to enhance the detection and management of CLDs, thereby increasing the TBdetection The PAL experiments in many countries around the world have been proven the high effectiveness 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 professional 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 1.3 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 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 leaders; 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 2.2.1 Study setting - Select purposeful districts in representing the province according to geography, economy, culture and social areas to study: + Two mountainous and highland districts: Vo Nhai and Dinh Hoa + Two mountainous districts: Dong Hy and Phu Luong; + Two midland districts: Pho Yen and Phu Binh - Select all communes in those 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, + 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 study design: + Cross-sectional descriptive + Community interventionwith controlled before-and-after study - The study was divided into 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 effectiveness of some solutions in improving the detection and management of CLDs at CHS after 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 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: n = Z2(1 - α/2)  p(1  Of that: d p ) + n is the minimum sample size; + Z(1 - α/2)with 95%confidencelevel, Z(1 - α/2) = 1.96; + pis the proportion of people with a good understanding of TB, according to the Nguyen Quoc Hoan study results0,5; + d iserrors between sample and population, d = 0.05 10 According 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 Sampling technique: Randomly select communes of study districts (each district selected commune) Randomly select 100 adults / commune - Collecting data on lung diseases at the CHS of study districts in 2013 and 2015 (before-after the intervention) * Sampling method for intervention research - Sample size: p1 (1- p1) + p2 (1- p2) n = Z () (p1 - p2)2 Of that: + p1: is percentage of CHWs practicebystandardmanagement on lung diseases, according to the previous studyresults was0.54; + p2: is percentage of CHWs wish to achieve properly management of lung diseases, this expected rate is to be achieved 0.8 + : statistical significance level, as 0.05 + : the probability of a type II mistake, as0.1 Samplepower is 90% + Z2 (): based on andcorresponding 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 study districts: 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 years in the control districts (same period of intervention in the intervention district); + Activity indicators between intervention districts and control districts at period times before and after the intervention; - Evaluating the intervention results based on efficiency index (EI) and Intervention effect (IE): P1  P  100 P1 Of that: p1 is the rate before and p2 is the rate after intervention + Efficiency index (EI) % = + Intervention effect(IE) = EIintervention- EIcontrol 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 2.4 Ethical approval This is a pilot study in the community to find appropriate solutionin improving the capacity of CHWs to detect and manage some CLDs at CHS In the study process, it did not have adversely affect the environment, health and got community acceptance The study was conducted after get ethic approval from the ethic council of Thai Nguyen University of Medicine and Pharmacy Chapter 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 3.1.2.1 Quantitative results Table 3.5 CHWs manage after asking, examining (n = 282) CHW implementation Management Diagnosing disease (or think of what disease) Providing specific management directions Telling patients about their diseases Instructing patients to follow up Appeasing the patient Writeclearlyand completely medical record Guiding patients to take sputum for TB testing Qualified N o 204 187 149 146 109 44 48 Rate % 72.3 66.3 52.8 51.8 38.7 15.6 17.0 14 The rate of CHWs were qualifiedmanagedafter asking questions and examining was very low, especially only 15.6% had clear and complete medical records; 17.0% guidedpatients to take sputum for TB testing 3.1.2.2 Qualitative results Box 3.1 Assessment of district and CHS staffsabout the situation of detecting and managing CLDs of CHWs Mr N.V.T - Van Han CHS, Dong Hy: “ The situation of lung diseases in Van Han commune as well as the other communes of Dong Hy district is still very severity Each year, the number of patients with lung disease symptoms visit CHS accounted for 25% –30%…” Mr H.S.H– Dong Hy district health center: “ The qualifications of CHWs are not high and equal, the examination and management of lung diseases are not good, not regularly guide people with pulmonary symptoms to get sputum for TB testing; skills for examination and management of general lung diseases are limited ” Mr T.V.T –Thanh Cong CHS: “ CHWs’ qualifications basically meet the standard requirements of common medical examination and management at the commune level, however, with chronic lung diseases and TB, which are specialized diseases, the CHWs' capacity is still limited in examination skills, diagnosis, management ” The CLDs is still common, the skills of detecting and managing CLDs of CHWs are still limited 15 3.2 Some related factors to the detection and management of some CLDs of CHWs in Thai Nguyen province 3.2.1 Direct related factor group Table 3.7 KAS of CHWs in CLDs detection and management (n=282) CHWs No Rate % Good knowledge 61 21.6 Not good knowledge 221 78.4 Good attitude 82 29.1 Not good attitude 200 70.9 Good skill 92 32.6 Not good skill 190 67.4 KAS The number of CHWs with good knowledge about the management of CLDs was only 21.6%, good attitude 29.1%, good skills only 32.6% Rate% Good 100 80 60 40 20 66.3 33.7 Not good 83 52.8 47.2 51.8 48.2 38.7 61.3 17 Chart 3.2 Counseling skills on CLDs of CHWs (n = 282) CHWs with good counseling skills on some CLDs were still low, especially instructing patients to take sputum for TB(17.0%) 16 3.2.1.2 Qualitative results Box 3.2 Assessment of district and commune medical staff on direct related factors to the capacity of CHWsin CLDs detection and management Mr N.V.V- Pho Yen district health center: “In general, the knowledge about CLDs of CHWs is limited, due to low and unequal qualifications of CHWs The CLDs such as bronchial asthma, COPD have less training, so they not know clearly, lead to confused diagnosis, not good management…” Mr D.V.T- Linh Son CHS “The CHWs attitude about CLDs management is still not good because they are unaware of the CLDs danger level, leading to subjectivity In addition, bronchial asthma and COPD require equipmentfordiagnosis support testing but there is no equipment at the commune level, so most case was managed by experience ” The direct related factors to the capacity of CHWsin detecting and managing CLDs were KAS about CLDs 3.2.2 Group of indirect influencing factors Table 3.8 KAP for prevention and control CLDs of people (n=400) People No Rate % Good knowledge 111 27.8 Not good knowledge 289 77.2 Good attitude 138 34.5 Not good attitude 262 65.5 Good practice 101 25.3 Not good practice 299 74.7 KAP 17 The rate of good knowledge about prevention and control CLDs was very low (27.8%); good attitude, 34,5%; good practice (25.3%) Table 3.9 Other indirect related factors Evaluation of CHWs Level Factor Good % Not good % CHS facilities 104 36.9 178 63.1 Medical equipment 96 34.0 186 66.0 TB communication materials 165 58.5 117 41.5 Enough vials to get sputum 253 89.7 29 10.3 Have enough CHWs as standard 162 57.4 120 42.6 258 91.5 24 8.5 226 80.1 56 19.9 119 42.2 163 57.8 207 73.4 75 26.6 32 11.3 250 88.7 Surveillance of district health center 187 66.3 95 33.7 Average numbers of comments 164 58.2 118 41.8 Vilage health workers supports CHWsin TB detection CHS develop plans to detectTB CHS develop plans to detectchronic lung diseases The involvement of party committee, commune committee Commune organizations are involved in the prevention of CLDs There was 41.8% CHWs assessed the not good level indirect related factors of CLDs prevention in the commune 3.3 Effectiveness some solutions in improving the detection and management of some CLDs of CHWs in Thai Nguyen province after years of intervention 3.3.1 Developed solutions: 18 - Solution 1: Enhanced capacity for CHWs, village health workers, commune women staffs, primary health care committee staffs and village leaders on prevention and control of lung disease in community - Solution 2: Enhanced communication activities - Solution 3: Developedchronic lung disease management unit (CMU) - Solution 4: Developed "Green breathing club" 3.3.2 Intervention effectiveness 3.3.2.1 Solution effectiveness: Enhanced capacity for CHWs, village health workers, commune women staffs, primary health care committee staffs and village leaders on prevention and control of lung disease in community * Some characteristics of CHWs in two selected groups: The intervention group included 78 CHWs, the control group included 78 CHWs Two groups were similar in KAS about CLDs management 80 76.9 71.8 62.8 70 79.5 75.6 65.4 Not good knowledge Rate % 60 50 40 30 20 Good knowledg Good attitude 28.2 24.4 34.6 37.2 23.1 Not good attitude 20.5 10 Good skill Not good skill Intervention team focus group Chart 3.4 Comparison of knowledge, attitude, skills in detecting and managing some CLDs of CHWsbefore intervention The CHWs in the intervention group had good knowledge 28.2%, good attitude 37.2%, good skills 23.1%; in the control group, it was 24.4%; 34.6%; 20.5% (p> 0.05) The KAS of two groups were similar 19 * Comparison the change in knowledge, attitudes, and skills to manage CLDs between two CHW groups of intervention and control after years: 97.4 96.1 100 79.5 69.2 Rate % 80 66.7 71.8 Good knowledge Not good knowledge Good attitude 60 Not good attitude 40 20.5 30.8 20 3.9 33.3 2.6 28.2 Good skill Not good skill Intervention team focus group Chart 3.6 Comparison the KAS of CHWs in two groups after the intervention After intervention, the CHWs in the intervention group had higher knowledge about detection and management of some CLDs than the control group: the good level was 96.1%, the good attitude 69.2%, good skill 97.4% The control group has indexes 20.5%; 33.3%; 28.2% (respectively), the significant difference with p