PAL
PA L
Practical Appr oach to Lung Health
Respiratory Care in Primary Care Services – A Survey in 9 Countries
For further information, please contact Stop TB Department
HIV/AIDS, Tuberculosis and Malaria World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland
Telephone: + 41 22 791 3923 Facsimile: + 41 22 791 4268
or visit our website at : http://www.who.int/gtb
Respiratory Care in Primary Care Services - A Survey in 9 Countries
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Edited by: Salah-Eddine Ottmani, Robert Scherpbier, Pierre Chaulet, Antonio Pio, Chris Van Beneden and Mario Raviglione
World Health Organization Geneva
2004
All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.
The named editors alone are responsible for the views expressed in this publication.
WHO gratefully acknowledges the valuable input and collaboration of the following investigators as well as the countries where the surveys took place:
Argentina: R. Colombini, O. Costantini Balestrino, C. Di Bartolo, H. Fernandez, I. Veronesi.
Chile: R. Soto, A. Yanez, M. Zuniga.
Côte d’Ivoire:B. Camara, D. Coulibaly, I.M. Coulibaly, B. Keita, G. Nekouressi.
Guinea: O. Bah-Sow, M.D. Barry, M.L. Camara, A. Diallo, M. Diallo.
Kyrgyzstan: A. Bakirova, N. Brimkulov, A. Kalieva.
Morocco: My. D. Alami-Marouni, N. Bencheikh, H. Ben-Issa, H.
Ben-Moussa, M. Chentoufi, F. Ezzerkali, L. Laâlou, J. Mahjour, M.Moussati.
Nepal: D.S. Bam, R. Bansha Saha, S.N. Chaudhary, Y.B. Khatri, G. Kamala, C. Lal Thapa, R. Mahato, M. Pangeni, N. Panthi, S. Rajbhandary, I. Smith, B.P. Thakur, R. Walley.
Peru: E. Alarcon, L. Loyola, R. Medina, E. Montes Garcia, M. Olivera, A. Salinas, P.G. Suarez.
Thailand: Y. Kasetjaroen, P. Pungrassami, H. Sawert.
We thank Christy Hanson for her valuable contribution.
We are also grateful to the United States Agency for International Development (USAID) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) for their financial support.
CONTENTS
LIST OF ACRONYMS AND ABBREVIATIONS... i
EXECUTIVE SUMMARY... iii
Background... iii
Description of the surveys ... iii
Results... iii
Conclusion ... v
1. INTRODUCTION... 1
1.1 Tuberculosis... 1
1.2 Acute respiratory infections ... 2
1.3 Asthma ... 3
1.4 Chronic obstructive pulmonary disease (COPD) ... 3
1.5 Need for health care standards for respiratory conditions in schoolchildren, adolescents and adults... 4
1.6 Assessing the burden and care of respiratory conditions in primary care... 5
2. MATERIALS AND METHODS... 6
2.1 Selection of study countries ... 6
2.2 Selection of PHC facilities... 6
2.3 Preparation of the surveys and data collection in countries... 6
2.4 Data entry... 8
2.5 Analysis ... 8
2.6 Statistics ... 9
3. RESULTS... 10
4. DISCUSSION... 14
4.1 Limitations of the study... 14
4.1.1 Study setting issues... 14
4.1.2 Representativeness issue ... 15
4.1.3 Comparability issues among survey countries ... 15
4.1.4 Potential misclassifications ... 16
4.1.5 Effect of sample size... 16
4.1.6 Other factors that may have influenced the results .... 16
Effects of climate and season ... 16
Effect of outdoor air pollution... 17
Effect of indoor air pollution... 17
Effect of tobacco smoking... 18
4.2 Burden of respiratory diseases in primary health care settings ... 19
4.3 Gender and respiratory conditions... 19
4.4 Age and respiratory conditions ... 20
4.5 General distribution of respiratory conditions... 21
4.6 Distribution of ARI cases... 22
4.7 Distribution of CRD cases ... 23
4.8 Diagnosis of TB... 24
4.9 Overall drug prescription ... 27
4.10 Antibiotic prescription... 28
4.11 Prescription of drugs other than antibiotics... 30
4.12 Management outcome ... 31
5. CONCLUSION... 33
6. REFERENCES... 37
ANNEX A: Multicentre study of respiratory disease management in PHC facilities with medical officers... 49
ANNEX B: Multicentre study of respiratory disease management in PHC facilities with nurses... 79
LIST OF ACRONYMS AND ABBREVIATIONS ARI ... acute respiratory infection
AURI ... acute upper respiratory infection ALRI... acute lower respiratory infection CB... chronic bronchitis
CRD ... chronic respiratory disease
COPD... chronic obstructive pulmonary disease DALY ... disability-adjusted life years
DOTS... internationally recommended strategy for TB control HIV ... human immunodeficiency virus
IMCI ... Integrated Management of Childhood Illnesses
ICD-10... International Statistical Classification of Diseases and Related Health Problems, Tenth Revision
PAL... Practical Approach to Lung health PHC ... primary health care
TB ... tuberculosis
EXECUTIVE SUMMARY
BACKGROUND
Respiratory conditions are very common in all populations and all age groups worldwide. They account for 19% of total deaths and 15% of disability- adjusted life years. Their distribution pattern is believed to be different between developed and developing countries because of differences in population age structure, exposure to risk factors and access to, as well as development of, health care services.
As of 1997, the Stop TB Department of the World Health Organization (WHO) initiated the development of a standardized and integrated
management strategy for patients, five years of age and over, who seek care for respiratory symptoms, with a focus on primary health care (PHC) settings. This strategy, called Practical Approach to Lung health (PAL), aims at improving tuberculosis (TB) case detection and the quality of TB diagnosis through the improvement of: i) the quality of respiratory case management and ii) the efficiency of respiratory care in health systems. Within the framework of the development of this approach, WHO undertook surveys in nine developing countries located in three different continents. The objectives were to evaluate the burden of respiratory conditions within PHC services, describe their distribution, assess the diagnosis process of TB, and identify the drug prescription pattern for respiratory patients in this setting.
DESCRIPTION OF THE SURVEYS
This report presents findings of ten surveys conducted, from August 1997 to February 2000, in Argentina, Chile, Côte d’Ivoire, Guinea, Kyrgyzstan, Morocco (2 surveys), Nepal, Peru and Thailand. All these surveys were undertaken in PHC facilities. In each country survey, at least three health facilities were involved for one to three months. The eligible individuals were patients, five years of age and over, who sought care for respiratory
symptoms in survey health facilities.
RESULTS
In the nine countries, surveys took place in 76 PHC facilities among which 54 (71.1%) involved medical officers and 22 (28.9%) nurses only. The number of PHC facilities surveyed per country varied from three in Morocco to 20 in Guinea. In the 76 PHC facilities, 29 399 respiratory patients were enrolled in the surveys; 25 585 (87.0%) of them were recruited in the health
facilities with medical officers and 3814 in the health facilities with nurses only. The number of respiratory patients varied tremendously across the survey countries: from 131 in Kyrgyzstan (with nurses only) to 5912 in Chile (with medical officers). The data suggest that among patients, five years of age and over, who visited PHC facilities for any reason, approximately 18%
are patients who sought care for respiratory symptoms (from 8.5% in health facilities with nurses in Nepal to 33.7% in health facilities with medical officers in Argentina). This proportion was consistently higher in males than in females.
Acute respiratory infections (ARI) are the most frequent in all the study settings and accounted for more than 80% of all respiratory conditions in many instances (from 49.6% in health centres with nurses in Nepal to 96.2%
in health centres with nurses in Kyrgyzstan). In most settings, the proportion of acute upper respiratory infections was higher than that of acute lower respiratory infections. Pneumonia was identified in only a very small proportion except in Côte d’Ivoire and Guinea.
Among respiratory patients, the percentage of TB suspects varied widely across countries: from 0% in Chile to 18% in Nepal; the overall percentage was below 10%. Most of TB suspects were referred to TB laboratories for sputum-smear examination except in Nepal. However, in some settings not all patients referred to TB laboratories were beforehand identified as TB suspects. In addition, in other countries, such as Guinea and Morocco, sputum-smear examination was not performed for more than 20% of the referred TB suspects. Among all respiratory patients, the overall proportion of pulmonary TB was about 1.4%.
The proportion of chronic respiratory disease (CRD) cases widely varied from 2 to 25%; but, it was significantly higher in the settings with medical officers (12.3%) than in those with nurses only (5.9%). The distribution of asthma and chronic obstructive pulmonary disease (COPD) within the CRD category widely varied as well as across countries.
At least 95% of respiratory patients were prescribed drugs in both types of PHC facilities. In many study countries, more than 50% of patients received antibiotic prescription and, in some countries such as Guinea and Morocco, this prescription accounted for more than 75% of respiratory patients. The number of drugs prescribed per respiratory patient exceeded one in almost all the study countries; but, it was more than two in Guinea. In general, ARI cases included the highest proportion of patients who were prescribed antibiotics. Amoxicillin and co-trimoxazole accounted at least for two-thirds of the prescribed antibiotics in both types of PHC facilities. Among all the
CONCLUSION
Respiratory conditions constitute a substantial part of the burden of diseases, among patients five years of age and over, in PHC settings. The distribution pattern of respiratory diseases varied across countries. This variation is not only associated with the methodological limitations of the surveys but also with the absence of standardization in categorizing respiratory conditions by PHC workers. Differences in training background between nurses and doctors, and across countries, exposure to air pollution, tobacco smoking and climate, and seasons during which surveys were carried out are likely also to contribute to this variation.
The survey findings suggest that in some health settings the criteria, recommended by WHO and its partners to identify TB suspects in PHC facilities are not fully used by the health workers in PHC. This is an obstacle to improve the quality of TB detection among respiratory patients and to reduce non-essential TB laboratory burden. The absence of standardized procedures to manage the various nosological categories of respiratory disorders may contribute to this weakness.
Comparison with data reported in the literature suggests that in general drugs are not over-prescribed in PHC setting. However, survey findings indicate that antibiotics are specifically over-prescribed.
Standardized procedures to manage respiratory patients five years of age and over should be developed. These procedures should be symptom-based and clearly normalized aiming at the most frequent respiratory conditions encountered in PHC settings. In addition, the referral and counter-referral conditions should also be clearly defined for respiratory cases between the health care levels within health system. These components are key elements of the PAL strategy.
1. INTRODUCTION
Respiratory diseases are very common in all age groups and generate a major demand on health care services worldwide. They are one of the most
common groups of health disorders observed in populations irrespective of country and/or community affluence level. The estimated annual death toll due to respiratory diseases (excluding measles, pertussis and diphtheria) is 10.5 million deaths worldwide. As such, they account for approximately 19%
of total deaths and 15% of disability-adjusted life years (DALYs) (1). Many respiratory conditions are related to environmental and behavioural factors and could, therefore, be prevented. That their distribution pattern is somewhat different between developed and developing countries reflects differences in population age distribution, exposure to risk factors and access to (and development of) health services.
In recent decades, the impetus of the international community in tackling preventable diseases and deaths has ensured that tuberculosis (TB) control and management of acute respiratory infections (ARI) in those under five years of age were emphasized in the development of basic health services.
However, chronic respiratory diseases (CRD) such as asthma and chronic obstructive pulmonary disease (COPD) are also important health issues in daily practice within health care services in many countries, particularly high and middle-income countries.
1.1 Tuberculosis
Globally, one person out of three is infected with the tuberculosis bacillus.
Every year, about 8.5 million people develop TB and 1.8 million die from it, mainly in developing countries (2, 3). Eighty percent of estimated TB cases worldwide occur in only 22 countries. The incidence of TB is increasing by approximately 0.4% per year globally; this increase is higher in countries of sub-Saharan Africa and the former Soviet Union (2). Estimates show that approximately 9% of TB cases in the 1549 age group are associated with human immunodeficiency virus (HIV) infection (3). In April 1993, the World Health Organization (WHO) declared TB a global health emergency and encouraged the WHO Member States to introduce the DOTS strategy as a part of a minimum health care delivery package. In this strategy, TB case management and TB control procedures are clearly formulated and standardized (4, 5). On a global scale, the objectives of WHO are to detect 70% of TB cases existing in populations and to cure 85% of them by the year 2005. The latest WHO report on global TB control reported that of the 210 WHO Member States, 155 (74%) had introduced and implemented DOTS activities in their national health system by 2001. Furthermore, it was
reported that 61% of the world population lived in areas where DOTS services were available. The same report also showed that, under DOTS conditions, 82% of TB patients are successfully treated, but that only 32% of existing worldwide TB cases are detected under DOTS requirements (2). To expand DOTS in countries, in recent years WHO and its partners have considered innovative approaches to increase the detection of TB cases.
1.2 Acute respiratory infections
The frequency of acute respiratory infections (ARI) in the global population is unknown. This category includes a range of respiratory conditions ranging from influenza episodes to severe, potentially fatal pneumonias. In most countries, ARIs represent one of the commonest reasons for seeking health care in the primary health care (PHC) setting, and they account for a significant proportion of morbidity and mortality. According to the World Bank, lower respiratory tract infections ranked third among the leading causes of death in 1990 and it is expected they will still be ranked fourth by 2020 (6). In developed countries, although mortality has dramatically decreased during the last century, ARI fatalities represent two-thirds of all deaths from communicable diseases (7). Most of these deaths occur in children and the elderly, and more than 50% of them are due to pneumonia.
For example, pneumonia is currently the sixth leading cause of death in the United States of America (USA) (8). In developing countries, ARIs account for 25% of mortality from all communicable diseases (7) and are, along with diarrhoeal diseases, the leading cause of death in children under the age of five. ARIs have been extensively studied in this age group, mainly in developing countries. This has provided a foundation for the development of standardized health interventions for the management of ARIs in children.
Such a strategy relies on a syndromic approach within PHC services. This approach is one of the main components of the Integrated Management of Childhood Illnesses (IMCI) strategy and it is now being implemented in many developing countries. In contrast, there have been few studies on ARIs in adults in developing countries. In most of those countries, there are no clearly standardized management procedures for ARIs in adulthood.
However, in developed countries, guidelines regarding management of lower respiratory tract infections and/or pneumonia have been issued by regulatory authorities including the European Respiratory Society (9), Canadian Infectious Diseases Society (8), Canadian Thoracic Society (8), American Thoracic Society (10), and the Infectious Diseases Society of America (11).
Guidelines for management of ARIs in adults have been also issued by scientific societies or professional associations in some developing countries.
However, the extent of their implementation and impact in the PHC setting
1.3 Asthma
Asthma is a common respiratory disease. Several studies have demonstrated that its frequency has increased over recent decades in both children and adults of both sexes (1214). Population-based investigations undertaken in several countries have found that its prevalence varies significantly among the world regions (1518). Asthma seems to be more frequent in
industrialized countries, predominantly European and north American countries, Australia and New Zealand , than in non-industrialized countries, and the prevalence is thought to be higher in urban than in rural areas (19).
Although it is well established that aeroallergens are the most important triggers for asthma attacks, the reasons asthma frequency has increased worldwide remain unclear. Air pollution and exposure to cigarette smoke do not fully account for this increase (13, 20). Adaptation to a western-type diet and reduction of infections in childhood, such as TB, are often highlighted as factors associated with asthma (13, 2125). Asthma awareness at a global level has been increasing, for the past few decades, as a result of the efforts of the international scientific community. The Global Initiative for Asthma has brought together most of the relevant partners to issue a guideline for asthma management and prevention to be used worldwide (26). The International Union Against Tuberculosis and Lung Diseases produced another guideline for asthma management in low-income countries (27).
These two guidelines have been widely distributed and assist in encouraging individual countries to develop their own guidelines. Both recommend the use of ß2-agonists and corticosteroids by inhalation. Recent studies have shown that these medications are not commonly prescribed in developing countries because of unavailability or prohibitive pricing, or because adherence issues arise with their long-term administration (28, 29).
1.4 Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease is a major cause of morbidity and mortality worldwide. Its frequency varies among countries and among sub- populations within countries. Prevalence, morbidity and mortality associated with COPD have increased over time and are higher in men than in women (3032). The temporal and geographical variations of COPD and inherent difficulties in collecting accurate data explain why it has been difficult to quantify its morbidity and mortality in developed and developing countries.
Most of the current information comes from developed countries but it is believed that this underestimates both morbidity and mortality (30, 33).
Some years ago, a study commissioned by WHO and the World Bank estimated the worldwide prevalence of COPD as 9.34/1000 in men and 7.33/1000 in women. In terms of lost DALYs, COPD ranked 12th in 1990 and is expected to be ranked 5th by 2020 (34, 35). This increase in
prominence reflects both a reduction in mortality associated with certain health disorders (e.g. heart diseases in developed countries and infectious diseases in developing countries) and an increase in cigarette smoking and environmental pollution in developing countries (36). Data from Canada, the Netherlands, the United Kingdom and the USA, suggest that, in developed countries, the frequency of COPD in men is increasing slowly or plateauing over time, whereas in women the increase is more significant (3739).
Tobacco consumption, chiefly cigarette smoking, is a major risk factor. The risk of developing COPD increases with the total pack-years smoked.
Occupational dusts and chemicals are also associated with COPD. It is believed that there is a genetic component involved in the development of COPD. Indeed, a severe hereditary deficiency in alpha-1 antitrypsin, although rare, is involved in the early development of panlobular emphysema (4041).
Other genetic factors, not yet clearly identified, might also be associated with COPD risk (4244). Bronchial hyper-responsiveness is believed to be implicated in the development of COPD (45). Several studies have consistently demonstrated a relationship between indoor air pollution from biomass fuels and COPD (4648). Other risk factors, such as infection in childhood, poor socioeconomic status and diet have been suggested, but to date no clear association has been fully established.
While on a global scale COPD has been recognized as a major cause of disease burden, official health authorities, particularly in developing countries, have not yet shown any clear commitment to tackling this disease in public health settings, or its control in their national health policy. On the contrary, in many developed countries, guidelines have been issued to specifically manage COPD within health services (31, 32, 49, 50). Recently, through the impetus given by WHO and the National Institutes of Health (USA), a global movement has been launched under the name of Global Initiative for Chronic Obstructive Lung Disease. This initiative aims to increase the awareness of policy-makers regarding COPD and to establish a sound health intervention for the management and prevention of this disease (30).
1.5 Need for health care standards for respiratory conditions in schoolchildren, adolescents and adults
Even though a strategy for ARI case management in children under five years of age is clearly defined, standardized and applied in many non-industrialized countries, the control of respiratory diseases in schoolchildren, adolescents and adults cannot rely on a similar health strategy. Indeed, implementation of guidelines for specific management of TB, ARI, asthma or COPD will
specialized resources to support it. Currently, in most non-industrialized countries, the management strategy for respiratory diseases is neither clearly formulated nor established within health services. This situation leads to the misinterpretation of the frequency of these diseases, inappropriate
prescription of medications, inefficient referral and counter-referral systems and a consequent waste of resources. The development of a standardized care management strategy for respiratory conditions in school-age children, adolescents and adults, and of coordination between health care levels is very much needed.
1.6 Assessing the burden and care of respiratory conditions in primary care
As of 1997, under the name of Adult Lung Health Initiative, WHO initiated the development of a combined management strategy for TB and respiratory diseases in school-age children, adolescents and adults. Subsequently, surveys were undertaken by WHO within the framework of this initiative, the name of which has recently changed to Practical Approach to Lung Health (PAL). These surveys took place in PHC facilities, with and without medical officers, in nine developing countries from three different continents. They involved patients with respiratory symptoms who sought care in these health facilities.
The objectives of the survey were to:
• evaluate the burden of respiratory diseases within PHC services;
• determine the distribution pattern of respiratory diseases and the relative frequency of each of them;
• assess the diagnosis process of TB among respiratory patients;
• identify the drug prescription pattern for respiratory patients within PHC services;
• assess the management outcomes of respiratory diseases in this setting.
The results of these investigations will help in the formulation of a standardized strategy for combined management of TB and respiratory diseases and its integration into PHC services. Furthermore, they will provide information to be used in the development of practical guidelines needed to implement this strategy.
2. MATERIALS AND METHODS
2.1 Selection of study countries
The study took place in selected countries from three continents: Africa, Asia and South America. The inclusion of a country as a study site was considered only if its national health authorities expressed their willingness to carry out and to follow up all the steps of the investigation in the field. Study countries were also selected on the basis that their PHC services included TB control activities. Ten countries were initially retained for the survey: Argentina, Chile, Côte d’Ivoire, Guinea, Kenya, Kyrgyzstan, Morocco, Nepal, Peru and Thailand. These countries have a wide range of TB burden; in 1997, the lowest estimated incidence was 13.0 new smear-positive TB cases per 100 000 inhabitants in Chile and the highest was 121.8 new smear-positive TB cases per 100 000 inhabitants in Kenya (51).
2.2 Selection of PHC facilities
A PHC facility was defined as a setting in which health care services, including curative care, were provided on an ambulatory basis either at first- facility level or at referral level and where care management of patients was ensured by nurses and/or medical officers. Each country eligible for the study had to involve at least three PHC facilities in the survey. The health facilities involved in the surveys were to represent typical PHC centres as defined by the national health authorities of the countries. The recommended study period was between one and three months in each facility surveyed. The facilities were selected on a convenience basis while taking into account the level of their involvement in PHC service delivery to communities, as well as patient access to microscopy services The number of health facilities to be involved was established by the individual country investigators according to their data collection and monitoring capabilities so as to ensure data quality for the study period. Morocco was the only country to be involved in two study periods. The overall data collection process started in Thailand in August 1997 and ended in Morocco in February 2000.
2.3 Preparation of the surveys and data collection in countries
In each country, the national TB programme staff organized training sessions for PHC workers and other staff involved in the data collection process. The
Revision (ICD-10) and the usefulness of the WHO Essential Drugs List in the surveys. The various forms to be used in the study were explained in order to ensure standardization of the data collection, and the role of each staff member involved in the study was clarified.
In every study health facility, a special register was implemented for the purposes of the survey. Participants were eligible for the study if they were aged at least five years and if they attended the selected PHC facilities with respiratory symptoms. Eligible patients who presented to the study facility were consecutively and prospectively registered on a daily basis during the established survey period. For each study participant, the following information was collected in the register: date of consultation, family and first names, sex and age, duration of symptoms, concomitant drug intake, underlying health condition, referral to other health facilities, diagnosis, treatment prescribed, and outcome within one month of the consultation.
No case definition was used by health workers to determine a diagnosis, except for suspected TB for which the following case definitions were used:
cough for more than two weeks in Argentina, Chile, Morocco and Peru, and cough for more than three weeks in Côte d’Ivoire, Guinea, Kenya,
Kyrgyzstan, Nepal and Thailand. However, a standardized procedure to categorize diagnosis was utilized. In PHC facilities with a medical officer, the diagnosis was established according to the ICD-10, while in health facilities staffed only by nurses it was reported as follows: acute upper respiratory infection (AURI), acute lower respiratory infection (ALRI), pneumonia, suspicion of TB, asthma and chronic cough. “Other” was used where the diagnosis could not be categorized.
Every one or two weeks, depending on the country, the number of patients who visited PHC facilities for any reason was disaggregated by age and sex from the curative consultation register. The number of children below five years of age who were notified in the register of ARI or IMCI programmes was also compiled by sex. In addition, TB suspects notified in the respiratory patients register used for the study were reported on another form. In this form the register identification number, family and first names, and the date of referral to microscopy of each TB suspect were recorded. The aim of this form was to regularly establish a list of TB suspects who consulted study PHC centres. From this list, each TB suspect case was traced in the
microscopy laboratory. Subsequently, a third form was completed recording whether TB suspects identified in study health facilities really underwent the requested sputum-smear examinations in the microscopy laboratories. If so, the investigator specified the number of sputum-smear examinations performed for each suspect case, the results of these examinations, and whether anti-TB treatment was initiated.
2.4 Data entry
Data were entered in data entry sheets in Excel, Access, Dbase or Epi-Info formats depending on the country. In Excel spreadsheets, data were aggregated by disease category or diagnosis and distributed by age group (less than 5, 5 to 14 years, 15 to 49 years and 50 years and over), sex, underlying health condition, ancillary tests solicited, drugs prescribed and outcome within one month of the visit. A standard Excel data entry sheet was used to compile data in Argentina, Côte d’Ivoire and Guinea. In Access, Dbase and Epi-Info formats, data on every study participant were entered in a data entry sheet including various descriptors referring to demographic characteristics, duration of symptoms, underlying health condition, referral to other health facilities, ancillary tests requested, diagnosis established, treatment prescribed, and outcome within one month of the consultation. A standardized Epi-Info format established by WHO was used in Kyrgyzstan and in the first study undertaken in Morocco. As the data entry process in this format was onerous, Chile, Morocco (second survey), Nepal, Peru, and Thailand developed their own data entry format in Epi-info, Access or Dbase.
Data in Access and Dbase formats were transformed into Epi-Info format at the data analysis stage.
2.5 Analysis
Data analysis was carried out for each country by type of PHC facility (with and without medical officers). Data were basically analysed by distributing the number of respiratory patients according to the characteristics for which information was collected in the study registers: age, sex, duration of symptoms, underlying health condition, referral to other health facilities, diagnosis, treatment prescribed and outcome within one month of the consultation. The burden of respiratory conditions within PHC services was assessed by calculating the proportion, by age group, of health care seekers for respiratory symptoms among overall patients attending PHC facilities for any reason. Age was grouped into three categories: 5 to 14 years, 15 to 49 years and 50 years and over. For analysis purposes, respiratory patients were categorized into ARI cases, suspect TB cases, chronic respiratory disease (CRD) cases and “others” for patients who had respiratory symptoms but could not be classified by health workers in one of these three categories.
ARIs were further stratified, on the one hand, into pneumonia and non- pneumonia and, on the other hand, into AURIs and ALRIs. The CRD cases were stratified into asthma, COPD/chronic bronchitis (CB) and other CRDs if data were collected in PHC facilities with medical officers, and into asthma and chronic cough if data were collected in health facilities with nurses only.
TB patients and among all respiratory patients attending PHC facilities were calculated. The proportions of respiratory cases, attending PHC facilities with or without medical officers, who were prescribed drugs, more specifically, antibiotics were calculated. Then, the most frequently prescribed antibiotics were identified and the relative frequencies of prescribed drugs other than antibiotics were calculated by type of health facility. The management outcome of respiratory conditions within one month of the consultation was categorized into: “lost to follow-up”, “improvement or cure”, “still sick”,
“diagnosis change” and “others”; this last category was used for the patients who could not be assigned to the first four categories.
2.6 Statistics
The statistical difference between two means was evaluated using the Student’st-test and between proportions using the chi-square test.
A statistical test was considered as significant when the p-value was less than 0.05.
3. RESULTS
The quality of data collected varied across countries. In some country settings, certain information was totally or partially omitted or was collected differently. For example, in Argentina, Côte d’Ivoire and Guinea, data on age were collected differently from the other countries; in Kyrgyzstan and Peru (centres with medical officers) the number of smear-positive cases was not reported although the number of suspected TB cases was considered. Surveys carried out in Côte d’Ivoire had the most missing data and those carried out in Morocco had the least. Consequently, in some circumstances data analysis could not be performed in depth. Missing data also resulted in discrepancies between the numbers of study participants included in tables that display the findings of the surveys (see Annexes A and B).
Of the 10 countries that were willing to implement the study, only Kenya failed to proceed. As a consequence, no data were analysed for this country.
In the nine remaining countries, 76 PHC facilities participated in the surveys.
Of these, 54 (71.1%) were providing health care services staffed by at least one medical officer, while 22 (28.9%) were staffed by nurses only. In five countries (Côte d’Ivoire, Guinea, Kyrgyzstan, Nepal and Thailand) health facilities with and without medical officers participated in the survey, whereas in Argentina, Chile, Morocco and Peru, the staff in each of the facilities were medical officers. The number of PHC facilities surveyed per country in each study period varied from three in Morocco (first survey) to 20 in Guinea. The number of health centres with medical officers varied from two in Nepal to 10 in Morocco (second survey). Those with nurses ranged from two in Côte d’Ivoire, Kyrgyzstan and Thailand to 11 in Guinea. The study period varied, from one country to another in terms of both duration and season (Tables 1A and 1B).
In the 76 health facilities, a total of 29 399 patients of five years of age and over presented with respiratory symptoms. Of this total, 25 585 (87.0%) were recruited in the 54 health facilities with medical officers and 3814 (13.0%) in the 22 facilities staffed by nurses only. The number of respiratory patients enrolled in PHC centres with medical officers ranged widely from 247 in Côte d’Ivoire to 5912 in Chile. Likewise, for patients recruited in centres with nurses only, this range was from 131 in Kyrgyzstan to 2289 in Guinea (Tables 1A and 1B).
Data collected in Argentina, Guinea, Morocco and Nepal indicated that, among patients attending primary care for any reason, 52% to 81% of the total patient population were five years or over, irrespective of the type of
ranging from 8.5% in Nepal to 33.7% in Argentina, with a median of 17.8%
and mean of 18.4%. In all settings, this proportion was consistently higher in male patients than in females (Tables 7A and 7B). However, among
respiratory patients, the proportion of females was consistently higher than that of males in both types of PHC facilities and in all countries with the exception of Nepal (Tables 2A and 2B). The overall sex breakdown was 56.1% female and 43.9% male. Furthermore, among all respiratory patients, irrespective of their age, the proportion of those five years and over varied from 31.7% in Guinea (with nurses) to 70.8% in Nepal (with nurses), with a median of 63.1% and an overall percentage of 43.1%. This proportion was consistently higher in females than in males irrespective of the setting (Tables 8A and 8B).
Age data were not collected on an individual basis in Argentina, Côte d’Ivoire or Guinea; therefore, the median and average ages could not be computed for the participants enrolled in those countries. For the six remaining countries, the median age range of respiratory patients was from 13 to 35 in settings with medical officers and from 30 to 33 in settings with nurses, with average age ranges of 20 to 39 and 32 to 37 respectively (Tables 3A and 3B). In all study settings with medical officers, average age differed significantly between females and males, although not in a particular direction (Table 4A); however, no such difference was identified in the settings with nurses (Table 4B). The distribution by age group varied appreciably among study settings. Comparison of the overall age group distributions showed a significant difference between the study settings with medical officers and those with nurses (2 =109.88, ddf = 2, p< 0.00001) without, however, identifying a particular age group distribution pattern in one of the two study settings (Tables 5A and 5B).
The proportion of patients who had visited a health facility for respiratory symptoms during the previous month varied widely across the study countries. The highest proportions (>21.0%) were observed in Kyrgyzstan and Thailand. The overall proportions were 9.3% and 12.5% in settings with medical officers and nurses respectively (Tables 9A and 9B).
Data on respiratory patient delay (from onset of symptoms) for consultation were collected in only four study countries: Kyrgyzstan, Morocco, Peru and Thailand. In health settings with nurses, more than 95% of the patients visited a health centre within three weeks of the onset of symptoms while in health settings with medical officers, a slightly lower percentage was observed for the same delay (Tables 10A and 10B). The frequency of an underlying health condition among those seeking health care for respiratory symptoms varied widely across countries. The overall proportions were 9.9% in health settings with medical officers and 31.0% in health settings with nurses (Tables 11A and 11B). However, these proportions seem to be influenced by the relatively high frequencies reported for cardiovascular diseases and tobacco
consumption in Kyrgyzstan and for malaria in Côte d’Ivoire. The most frequently reported underlying conditions are presented in Tables 12A and 12B.
The distribution of respiratory patients by diagnosis category indicated that in all study settings, ARI cases were most prevalent, and in some situations they accounted for over 80% of cases. The proportion of TB suspects varied widely, in both types of health care settings, from 0% in Chile to 18% in Nepal and overall was below 10%. The proportion of CRD cases varied widely in both types of health care settings: from 2% to 25%. However, this proportion was significantly higher in the settings with medical officers (12.3%) than in those with nurses (5.9%). The frequency of patients with respiratory symptoms who were not categorized as ARI, suspect TB or CRD cases was high in certain study settings such as Côte d’Ivoire and Peru (Tables 13A and 13B).
In most settings, irrespective of facility type, the proportion of AURI cases was higher than that of ALRI cases with the exceptions of Côte d’Ivoire (both types of facilities) and Guinea (with medical officers) (Tables 14A and 14B). Pneumonia was generally identified in only a tiny percentage of cases (Tables 16A and 16B). For example, in PHC centres with medical officers, its overall proportion among all respiratory patients was 2.8 %. In settings with medical officers, there were great variations in the distribution of CRD cases among study countries with regard to asthma and CB/COPD, while in Guinea and Morocco (2nd survey) a substantial percentage of CRD cases was not identified as being either asthma or CB/COPD (Table 15A). In study sites with nurses, the number of asthma cases identified was proportionally higher among patients categorized as CRD cases (Table 15B).
Data collected in settings with medical officers indicated that the proportion of patients for whom at least one ancillary test was requested by the
physician varied among study countries from 1.0% in Argentina to 65.8% in Kyrgyzstan (Table 17A). In PHC facilities with nurses, this proportion did not exceed 22% (Table 17B). Among ancillary tests, laboratory tests were requested much more frequently than other tests (Tables 18A and 18B).
Findings suggest that, among laboratory tests, sputum-smear examination was often requested by health workers for patients with respiratory symptoms (Tables 19A and 19B) with this phenomenon being more consistent in study settings with medical officers. Although there were variations among countries and incomplete data, the proportion of TB suspects, among patients for whom sputum-smear examinations were requested, was high in countries such as Guinea, Morocco, Peru and Thailand. This proportion was low in other countries, for example in Chile where sputum-smear examination was
TB laboratories for sputum-smear examination in both types of PHC settings, with the exception of Nepal (Tables 21A and 21B). In some countries, such as Guinea and Morocco, more than 20% of patients referred to the TB laboratory did not undergo sputum-smear examination. The proportion of smear-positive cases among patients for whom sputum-smear examination was requested varied widely across countries and between the two types of study settings (Tables 22A and 22B). In general, the confirmation rate of pulmonary TB by sputum-smear examination was high except in Thailand (with medical officers) (Tables 23A and 23B). Among all patients who attended both types of PHC facilities for respiratory symptoms, the
proportion of confirmed pulmonary TB cases was generally low or very low, except in Côte d’Ivoire and Nepal. The overall proportion of pulmonary TB, in both types of study settings, was approximately 1.4% (Tables 24A and 24B).
In both types of PHC facilities, most respiratory patients (at least 95%) received a drug prescription from health workers. In many study settings, more than 50% of patients received an antibiotic prescription and in some countries, such as Guinea and Morocco, more than 75% of patients were prescribed antibiotics (Tables 25A and 25B). The proportion of antibiotic prescription by respiratory disease category could not be estimated for Argentina, Côte d’Ivoire and Guinea. However, in both types of study settings, this proportion varied among the remaining countries. In general, patients categorized as AURI or ALRI had the highest proportion of antibiotic prescription (Tables 26A and 26B). The prescription pattern of antibiotics was somewhat different across countries and study settings.
Overall, amoxicillin and co-trimoxazole accounted for at least two-thirds of prescribed antibiotics in both types of study settings (Tables 27A and 27B).
Other frequently prescribed drugs included antipyretics (in general aspirin or paracetamol), bronchodilators and mucolytics/antitussives (in PHC with medical officers) and antimalarial drugs (in health facilities with nurses;
Tables 28A and 28B). The average number of drugs prescribed per
respiratory patient exceeded one in all study sites and was more than two in Côte d’Ivoire (in health settings with nurses) and Guinea (Tables 29A and 29B). The proportion of antibiotics among all prescribed drugs varied widely across countries: from 28.4% in Argentina to more than 60% in Côte d’Ivoire and Nepal. The overall proportion of antibiotic prescription was 41% and 37% in health settings with medical officers and nurses respectively (Tables 30A and 30B).
Data showed marked variations in overall patient outcomes across the study countries. However, the findings suggest that the proportion of respiratory patients who were lost to follow-up was high in both types of study settings, but tended to be higher in health settings with medical officers (Tables 31A and 31B).
4. DISCUSSION
In developing countries, there is little information on respiratory diseases in populations aged five years and over, while much more information is available for ARI in children and for TB. Our surveys attempted to fill this information gap. Their findings highlighted the main characteristics of patients aged five years and over who had sought health care for respiratory symptoms in PHC facilities. However, our surveys had several limitations because of their non-uniformity in terms of geographical regions, study periods, study populations, health care delivery practices and data collection procedures used. Nevertheless, they did provide primary information on the frequencies and the management of respiratory diseases within primary care services in developing countries.
4.1 Limitations of the study
The survey results should, however, be interpreted cautiously while taking account of their various limitations.
4.1.1 Study setting issues
It was not always possible to report overall survey findings because of the inherent variability among study sites. This variability is associated with various factors. Overall results would have been influenced by the data collected in the health centres with medical officers since more than 80% of the 29 399 study participants were enrolled in these health facilities.
Furthermore, the level of qualification in identifying respiratory disease categories was not the same between nurses and medical officers practising in the two types of PHC facilities. This may explain some of the observed differences in respiratory disease distribution between these two settings within the same country. For example, in Côte d’Ivoire and Kyrgyzstan, more than 90% of respiratory patients were identified by nurses as having ARIs, while approximately 50% and 70%, respectively were diagnosed similarly by medical officers (Tables 13A and 13B). Furthermore, the categorization procedure for respiratory conditions was not the same in the two types of PHC settings. Medical officers identified respiratory diseases according to the ICD-10, while nurses used broad categories (UARI, ALRI, suspect TB and CRD), and pneumonia and asthma had to be individualized.
4.1.2 Representativeness issue
PHC facilities involved in these surveys were not selected on the basis of a random sampling procedure. Rather, they were selected on the basis of activity intensity in health care delivery to the population of their catchment area. In fact, standardized criteria allowing this selection were not clearly specified in the study protocol, except the requirement for the involvement in TB control. The selection procedure was therefore established by the
individual countries. Consequently, the number of health centres involved per country and per type of PHC facility varied. This may have had an effect on the data comparability among countries. Study participants enrolled in only a few health facilities were less likely to be representative of the country overall than those recruited from a larger number of health centres.
In addition, the recruitment of patients with respiratory symptoms in a given health facility might depend on the population characteristics of the
catchment area. Health facilities providing health care services to populations with different characteristics may have different burdens and/or categories of respiratory disease. Those characteristics are related to socioeconomic status, demographics, behavioural factors such as smoking, occupational factors such as exposure to industrial pollutants as well as domestic and
environmental factors including indoor and outdoor pollution (15).
4.1.3 Comparability issues among survey countries
Although it is assumed that physical access to health care services was equivalent for populations served by the selected PHC facilities within a given study country, it is unlikely that this was actually the case among the nine countries. For example, physical access to health services is likely to be easier in Argentina or in Chile than in Nepal. If the size of populations served by the health centres involved in the study was the same within a given country, it might differ among study countries. The higher the population size of the catchment area of a given PHC centre, the higher the workload would be in that centre, with shorter patient consultations and reduced quality of care being delivered as a consequence.
The involvement of private health workers in providing traditional or modern health care services to the catchment populations might also differ
considerably among the study countries. For example in Kyrgyzstan and Guinea, the private sector is poorly developed whereas in Morocco, 50% of physicians practise exclusively within this sector.
These factors related to the population characteristics and to the development of the health service system may influence the attendance level at PHC centres by care seekers from the community. However, it is not clear how influential these factors are in terms of attendance at study health centres by
patients with respiratory symptoms and in terms of respiratory disease distribution. It is difficult to gauge the burden of respiratory disease within PHC services had these factors not existed. Furthermore, as the
characteristics and frequencies of these factors are likely to differ among study countries, variations in our results might be partially explained by these differences.
4.1.4 Potential misclassifications
The fact that standardized case definitions were not used, with the exception of TB suspect case, highlights a likely source of disease misclassification.
This bias may increase because a relatively small number of medical officers and nurses were responsible for the categorization of 29 399 patients with respiratory symptoms. Thus, potential errors that a given health worker could make in establishing a diagnosis would be most likely repeated
systematically, such that the higher the number of patients per health worker the stronger the error in the survey. In our surveys, the number of health workers involved in establishing diagnoses was not documented for all the study countries. For instance, in the two studies undertaken in Morocco, two physicians per health centre were involved in this process with approximately 190 and 180 respiratory patients being diagnosed per medical officer in the first and the second surveys, respectively. This potentially systematic error, which constitutes the basis of misclassification, may also differ among medical officers and among nurses within a given study country.
4.1.5 Effect of sample size
The number of study participants varied widely among countries (Tables 1A and 1B). Among the 25 585 respiratory patients identified in PHC facilities with medical officers, 52.3% were collectively enrolled in Argentina, Chile and Peru, whereas in health centres with nurses, 60% of the overall study participants were recruited in Guinea. Thus, it is clear that findings from the data sets of those countries heavily influenced the overall results of the study in comparison with the data collected in health centres with nurses of Kyrgyzstan or in those with medical officers of Côte d’Ivoire, for example, where smaller sample sizes were employed.
4.1.6 Other factors that may have influenced the results Effects of climate and season
The surveys were carried out in counties with different climates. For example, Kyrgyzstan and Nepal have a continental climate, while Côte d’Ivoire, Guinea and Thailand have a tropical climate and Morocco has a
season during which the weather remains cool in Kyrgyzstan and in many areas in Nepal, while the period from December to February is the cold season in Morocco. Usually these two factors influence the occurrence of respiratory conditions in any population and, subsequently, the attendance at PHC facilities by patients with respiratory symptoms. ARI cases are frequent in the cold season, particularly from December to February, in the northern hemisphere (52) and respiratory viruses, including influenza, are also widespread in this period (53). Previous studies conducted in PHC facilities throughout Morocco in 1994 and 1995, indicated that there was a sharp increase of ARI cases in children in January–February and a sharp decrease in August (54). Studies in developed countries have shown that when the temperature falls in winter, there is an increase in care demand for respiratory diseases in general practices and hospital settings (55–57). Care demand among patients for asthma or allergic rhinitis usually follows a seasonal pattern. Studies in developed countries have shown that respiratory episodes follow peaks of allergic particles, such as pollens or mites (58–60). Other climatic factors, such as precipitation or a rise in barometric pressure, might also increase respiratory discomfort in susceptible patients (61), and subsequently the attendance of respiratory cases at PHC facilities.
Effect of outdoor air pollution
Outdoor levels of air pollution in the study countries are likely not to be identical, reflecting differences in the degree of urbanization, level of industrialization, type of industrial technology adopted, number and age of motor vehicles on the road and availability of regulations on air quality. Most of the PHC centres involved in our surveys were located in urban areas. This factor may somewhat explain the variations of our results among study countries, since the association between atmospheric pollution and respiratory disorders has been extensively documented, mainly in children and the elderly, in European and north American countries particularly since the 1950s. Longitudinal studies have shown an association between levels of sulfate particulates, ozone in warm season, and other air pollutants and an increase in mortality from heart and respiratory diseases (62–64). In Santiago, Chile, an ecological study demonstrated a relation between air pollutants and mortality, in adults, from COPD and asthma independently of socioeconomic and living conditions (65). Data from another study
undertaken in Casablanca, Morocco, which used mathematical modelling to control for variations in season, temperature, humidity and care demands, suggested an association between black smoke-type fine particulates and daily consultations in PHC facilities for asthma attacks and acute bronchitis in patients over five years, as well as for AURI and ALRI in children under five years (66).
Effect of indoor air pollution
The relationship between indoor air pollution and the occurrence of respiratory symptoms is often reported. Most indoor air pollution is due to
domestic use of fuel for cooking or heating, but it is also thought that housing conditions, building architecture, ventilation systems and indoor presence of animals, such as cattle or pets, contributes to this pollution. The study countries have different geographical locations where populations use various energy sources depending on their cultural habits and living conditions.
These differences influence the type and the level of indoor air pollution and may contribute to the variations in our results among study countries.
Unprocessed biomass fuels, in the form of wood, crop residues and animal dung, are used, as a domestic energy source, for cooking and heating by about 50% of world households mainly in developing countries (47, 67, 68).
Fuels, as a function of their type, generate different levels of air pollutants.
Types of energy sources are likely to differ among our study countries depending on their availability and the energy policy of the country. For example, bottled gas is widely used domestically in Morocco, whereas wood and coal are more frequently used in Guinea and Côte d’Ivoire and wood, grass and crop residues are commonly used in Nepal (69). The association between biomass fuel smoke and respiratory conditions has been particularly studied in women and young children (48). The risks of ARI and CB/COPD related to exposure to indoor biomass smoke are often highlighted in the literature (46, 47, 67, 68, 70–75)
Effect of tobacco smoking
The harmful impact of tobacco smoking on human health, particularly on the cardiovascular system and respiratory tract, is well established. Thus, variations in the results obtained among the study countries may also be partially explained by the difference in frequency of smoking among their populations. Indeed, the prevalence of smoking varies in adult males from more than 60% in Guinea and Kyrgyzstan to 38% in Chile and in adult females from 25% in Chile to 6% or less in Côte d’Ivoire and Thailand (76, 77). Related studies have demonstrated differences in cigarette consumption per capita among our study countries (77).
The causal relationship between tobacco and lung cancer has been well established. Tobacco smoking is also the main risk factor for COPD
development. Moreover, it is well known that respiratory symptoms and lung function abnormalities are more frequent among smokers than non-smokers.
The association between tobacco consumption and pneumonia in adults has also been highlighted as it is estimated that the population-attributable risk of smoking is approximately 32% of pneumonia cases (78).
4.2 Burden of respiratory diseases in primary health care settings Data collected in Argentina, Guinea, Morocco, Nepal and Thailand indicated that approximately 18% of patients over five years of age who attended PHC facilities sought health care for respiratory symptoms. In the literature, it was not possible to find results from other studies where the respiratory disease burden was assessed in patients five years of age and over within PHC services in developing countries. However, a recent study in Botswana reported that, in 1997, 18% of outpatients 15 years of age and over had respiratory conditions (79). Another study reported approximately 20%
respiratory conditions among primary care attendees, including children below five, in 22 health posts in Nepal (80). Data from the United States showed that , in 1997, 21% of total visits to family physicians concerned respiratory patients (81); however, these data appeared to include all age groups. It is clear that it is difficult to assess what the typical burden of respiratory diseases in PHC settings would be in developing countries because of the lack of studies and variations that might occur between studies due to the factors we discussed above. However, given that the percentage of 20% is somewhat reproducible in the rare findings available, it is a
reasonable assumption that one of five care seekers, aged five years and over, attending PHC facilities is a patient with respiratory symptoms. This estimate should be confirmed in further investigations. Standardized management of ARI in children under five years of age has been developed and implemented in many developing countries, often within the framework of IMCI initiated by WHO and other international partners. Although there are variations among countries, our findings suggest that between one-third and two-thirds of respiratory patients (Tables 8A and 8B) are likely to be empirically managed within PHC services, since a clearly formulated and standardized management strategy has not yet been adopted in most developing countries for respiratory patients aged five years and over. The ongoing development of PAL strategy by WHO is aiming to address this challenge, with a focus on PHC setting.
4.3 Gender and respiratory conditions
Our findings showed that, in general, among patients with respiratory symptoms who attended PHC facilities, the proportion of females was higher than males (Tables 2A and 2B). Irrespective of age, 55% to 60% of patients who visited PHC facilities for any reason were female, and among these, the proportion of those over five years of age was higher than that among males (Tables 6A and 6B). These data suggest that basic health services are used primarily by females. Women may visit PHC centres because of their accessibility or their proximity to their homes. In fact, data from Kyrgyzstan, Morocco, Peru and Thailand showed that a substantial proportion of
respiratory patients consulted health services within three weeks of the onset of symptoms (Tables 10A and 10B). Furthermore, more than 95% of the
patients who attended PHC facilities staffed by nurses did so within this period. Such health centres are usually located peripherally, and, as a consequence, may be more physically accessible than health facilities with medical officers. It is possible that women are more health-conscious than men and that they will take action to seek care wherever it is possible.
However, this remains to be fully documented. Furthermore, in many developing countries, women, especially those who are young, have less disposable income than men to consult private health care providers (82).
Thus, data indicating a higher proportion of females in PHC services do not mean that males are not visiting other health care settings such as hospitals or private sector facilities. A recent study carried out in 40 private general practitioners in Morocco reported that females over five years of age, with an average age of 33, represented 50% of care-seekers for respiratory symptoms (83). In the second of the current Moroccan survey, undertaken in the public sector of the same provinces, females with an average age of 25, made up 62% of care-seekers. Another study carried out in Viet Nam among patients having a cough for more than three weeks, showed that women tended to take health care actions more often than men through self-medication, pharmacists or general practitioners, whereas men visited hospital more often than women (84).
4.4 Age and respiratory conditions
The data presented here suggest that, among patients of five years of age and over, demand for health care delivery for respiratory conditions in PHC facilities is higher in males than in females (Tables 7A and 7B). More than 80% of respiratory patients are between 5 and 50 years of age, of which approximately half are young adults (15–49 years) and half are between 5 and 14 (Tables 5A and 5B). This distribution is almost identical between females and males (data not shown). One can extrapolate that young male adults are more likely to be exposed to respiratory risk factors, such as cold weather or tobacco smoking. Airways behave differently in females and males throughout the human lifespan, reflecting dimensional, immunological, hormonal, environmental, social and cultural factors. Indeed, forced
expiratory flow rates are lower in boys and young men than in girls and young women and the rate of acquisition atopy is higher in males than females up to 15–25 years of age (85). This suggests that boys and male adolescents have relatively narrower airways than girls and female adolescents and that this makes them more susceptible to respiratory disorders such as infection and asthma (69, 85).
4.5 General distribution of respiratory conditions
In both types of PHC facilities, the overall study findings showed that at least 80% of respiratory patients had ARI, and approximately 5% were suspected TB cases. In general, the proportion of patients with a chronic respiratory condition is higher in health facilities with medical officers than in health centres staffed by nurses alone (Tables 13A and 13B). This may be related to the fact that patients are often referred from the very peripheral level to health centres with doctors, where they may remain for their follow-up.
However, because of the chronic nature of respiratory symptoms and their previous experiences with the health system, some patients may directly visit health centres with medical officers, thereby bypassing the first level of health care.
A substantial proportion of patients were not categorized as ARI, TB suspect or CRD but as “other” in certain PHC facilities with nurses (Nepal) or with medical officers (Côte d’Ivoire and Peru). The category “other” was assumed to include patients with respiratory symptoms due to non-respiratory
conditions such as heart disease or anaemia. However, it is possible that health workers involved in these surveys failed to categorize groups of patients in the manner proposed in the study protocol. Furthermore, there were tremendous variations in the distribution of categories of respiratory disease (Tables 13A and 13B). In Nepal, the proportion of TB suspects was the highest (more than 15%) in both types of health care settings. The fact that TB is a major public health problem in that country does not fully explain why there was this level of reporting, in comparison with countries such as Guinea, Morocco, Peru and Thailand, where TB is also prevalent in public health settings. The case definition for TB suspects during the survey in Nepal might have been, in practice, different from that used in the other countries. Data from Morocco and Peru would have been expected to indicate a higher proportion of TB suspects than those from Nepal. Indeed, TB is suspected in Morocco and Peru when the patient has been coughing for two weeks and more, whereas in Nepal this time period is three weeks and more.
High proportions of CRD were reported in Chile, Côte d’Ivoire, Kyrgyzstan and Nepal compared with the other countries which, in general, had higher proportions of ARI (Tables 13A and 13B). This may reflect not only methodological issues inherent in these surveys, but also differences in factors associated with respiratory disease occurrence discussed above.
4.6 Distribution of ARI cases
Patients with AURI predominated among ARI cases, with their overall proportion being higher in PHC facilities staffed by nurses alone than in those with medical officers (Tables 14A and 14B). In countries where the surveys were carried out in PHC facilities with both nurses alone and with medical officers, namely Côte d’Ivoire, Guinea, Kyrgyzstan, Nepal and Thailand, the proportion of AURI cases among ARI patients was always higher in study facilities with nurses (Tables 14A and 14B). Thus, it is possible that nurses tended to categorize ARI as AURI more than as ALRI;
but, there is no evidence to support this speculation. However, the higher proportion of ALRI cases in PHC facilities with medical officers might also reflect the fact that patients with ALRI tended to consult medical officers directly in comparison to patients with AURI, since major clinical symptoms are more frequently experienced in ALRI. The procedures used to distinguish AURI and ALRI cases were likely to be different between nurses and medical officers because their training backgrounds and work routines are different, as is, in some settings, their access to some diagnostic equipment. It is striking, for instance, that in PHC facilities staffed by nurses in Thailand, none of the 370 ARI cases was categorized as ALRI (Table 14B). This example suggests that health workers in PHC services might inaccurately perceive a substantial proportion of respiratory conditions if there are no standardized procedures to identify the different categories of respiratory disorders at this health level. In comparison to the other countries, a high proportion of ALRI was reported among ARI cases in Guinea (Table 14A) and Côte d’Ivoire (Tables 14A and 14B). It is not clear why there was such a high proportion in the two African countries involved in our surveys. It is important to highlight that Côte d’Ivoire and Guinea are located in the tropical area of western Africa where the ecology of microorganisms differs from that in the other countries with temperate or continental climates.
Pulmonary infections due to particular agents that are more prevalent in tropical regions might partially explain this high proportion. It is well known that parasitic diseases like helminthic and protozoal diseases can also affect the lungs (86). HIV infection, which is more common in Côte d’Ivoire than in Guinea, may influence the symptomatic presentation of respiratory patients resulting in the identification of more ALRI cases in PHC services. Data from Botswana, where HIV infection has been increasing in the past two decades, have shown that mortality from pneumonia in hospitals increased three-fold between 1986 and 1997 (79). In poor urban settings, overcrowding may contribute to high transmission rates of pathogens. For example, in mining communities in South Africa, the attack rate of pneumonia in adults was as high as 10% per year in the early 20th century (87).
