Implementing lung health interventions in low- and middle-income countries: a FRESH AIR systematic review and meta-synthesis

Abstract

The vast majority of patients with chronic respiratory disease live in low- and middle-income countries (LMICs). Paradoxically, relevant interventions often fail to be effective particularly in these settings, as LMICs lack solid evidence on how to implement interventions successfully. Therefore, we aimed to identify factors critical to the implementation of lung health interventions in LMICs, and weight their level of evidence.This systematic review followed Cochrane methodology and PRISMA reporting standards. We searched eight databases without date- or language restrictions in July 2019, and included all relevant original, peer-reviewed articles. Two researchers independently selected articles, critically appraised them (using CASP/MetaQAT), extracted data, coded factors (following CFIR), and assigned levels of confidence in the factors (via GRADE-CERQual). We meta-synthesised levels of evidence of the factors based on their frequency and the assigned level of confidence. (PROSPERO:CRD42018088687)We included 37 articles out of 9111 screened. Studies were performed across the globe in a broad range of settings. Factors identified with a high level of evidence were 1) Understanding needs of local users, 2) ensuring Compatibility of interventions with local contexts (cultures, infrastructures), 3) identifying influential stakeholders and applying Engagement strategies, 4) ensuring adequate Access to knowledge and information, and 5) addressing Resource Availability. All implementation factors and their level of evidence were synthesised in an implementation tool.To conclude, this study identified implementation factors for lung health interventions in LMICs, weighted their level of evidence, and integrated the results into an implementation tool for practice. Policymakers, non-governmental organisations, practitioners, and researchers may use this FRESH AIR Implementation tool to develop evidence-based implementation strategies for related interventions. This could increase interventions’ implementation success, thereby optimising the use of already-scarce resources and improving health outcomes.

Implementing a context-driven awareness programme addressing household air pollution and tobacco: a FRESH AIR study

“…Notably, rates for adequate adoption of the stoves were substantially higher in Kyrgyzstan compared to stove adoption rates from other studies. Adoption rates are often not reported in clean cookstove studies; if they are, it is commonly mentioned the rates are 'strikingly low', 'disappointing', or around 4-10% 11,44 . However, stove stacking occurred substantially more frequently in Vietnam in our study, suggesting that, besides knowledge, other causes also contribute to inadequate clean cooking practices.…”

“…An important reason for implementation failure is the misalignment of local knowledge and beliefs with the interventions offered and their implementation strategies [15][16][17][18][19] . If there is no locally perceived need for change, motivation for behaviour change is low 20,21 .…”

Factors critical to implementation success of cleaner cooking interventions in low-income and middle-income countries: protocol for an umbrella review

“…This study is part of a larger study conducted by Brakema et al 22 This latter study focused on critical implementation factors for interventions targeting chronic lung disease in LMICs, as part of the Horizon 2020 Free Respiratory Evaluation and Smoke-exposure reduction by primary Health cAre Integrated gRoups (FRESH AIR) project. 23 Because the search resulted in a high number of articles that focus on the implementation of cleaner cooking interventions, it was decided to split the review into two parts.…”

“…The study is registered at PROSPERO (CRD42018088687). Because the methodology for this umbrella review differs from the methodology used in the review by Brakema et al, 22 and because an umbrella review of systematic and narrative reviews is not common, 24 25 it was decided to record the protocol for this study to increase transparency.…”

“…The initial search was part of the study conducted by Brakema et al 22 The search strategy was developed together with a certified medical librarian. Search terms included (synonyms of) implementation, LMICs and interventions targeting chronic lung health, including cleaner cooking interventions.…”