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

Chronic respiratory diseases (CRDs), particularly COPD, are a significant global health burden, with the majority of deaths occurring in low- and middle-income countries (LMICs). Major risk factors include smoking and HAP. Implementing interventions to address these risks in LMICs is challenging due to misalignment between interventions and local knowledge, beliefs, and resources. Low awareness of CRDs and limited resources hinder effective prevention. A Ugandan program, utilizing a capability, opportunity, motivation-behavior (COM-B) model and a train-the-trainer approach with community health workers (CHWs), demonstrated feasibility, acceptability, and effectiveness. This study aimed to assess the feasibility, acceptability, and effectiveness of translating this program to Kyrgyzstan and Vietnam, providing guidance for global adaptation.

Existing literature highlights the challenges of implementing CRD interventions in LMICs due to contextual factors. Misalignment between interventions and local knowledge and beliefs leads to low motivation for behavior change. Poverty further complicates the issue, particularly regarding the adoption of cleaner fuels and stoves. The Ugandan program, based on the COM-B model, served as a promising foundation for translation, using a cascading train-the-trainer approach, leveraging the crucial role of CHWs in primary healthcare delivery in low-resource settings. However, translating evidence-based interventions effectively remains a major challenge, with limited guidance on adapting CRD prevention programs to diverse contexts.

This prospective implementation study, conducted between 2016 and 2018 within the FRESH AIR project, used a modified Conceptual Framework for Implementation Fidelity. Kyrgyzstan and Vietnam were selected purposively due to high CRD prevalence and exposure to HAP and tobacco. The study employed a cascading train-the-trainer approach: HCWs were trained first, followed by other HCWs, CHWs, and finally communities. Training materials were adapted to local contexts. Feasibility, acceptability, and fidelity were evaluated using qualitative data collected through discussions and quantitative data collected through knowledge questionnaires and surveys assessing stove usage. Statistical analysis included Wilcoxon signed-rank tests for knowledge scores and descriptive statistics for stove usage.

The awareness program was implemented as planned, within budget (€11,000 per country), and within the 3-year timeline. Feasibility and acceptability were high. Significant improvements were observed in knowledge questionnaire scores among all groups in both countries, with Kyrgyzstan showing a larger increase due to lower baseline knowledge. Stove acceptability was high (100% in Kyrgyzstan, 89.8% in Vietnam), but adequate stove use was higher in Kyrgyzstan than Vietnam, possibly due to factors like stove size. Kyrgyzstan demonstrated substantially higher stove adoption rates compared to other studies, while stove stacking was more frequent in Vietnam, suggesting contextual factors influence behavior change beyond knowledge. Engagement of local stakeholders and adapting the program to local contexts were crucial for success.

The successful translation of the awareness program to Kyrgyzstan and Vietnam demonstrates the feasibility and effectiveness of adapting a proven intervention to diverse LMIC settings. The significant knowledge gains and positive changes in stove acceptability highlight the program's impact. Differences in behavior change between countries emphasize the importance of considering contextual factors, such as stove characteristics and existing health education practices. The study aligns with WHO guidelines emphasizing the role of CHWs and contextual factors in implementation success. The findings offer valuable guidance for implementing similar interventions globally.

Contextualizing a train-the-trainer awareness program for lung health is feasible, acceptable, and effective in diverse LMIC settings. Increased awareness empowers communities to reduce exposure to risk factors, ultimately improving lung health. Future research could explore long-term behavioral changes and the impact on CRD incidence, as well as examine the cost-effectiveness of different program adaptations.

The study relied on self-reported implementation integrity, potentially leading to overestimation of fidelity. Knowledge questionnaires were developed for the study and may not have been fully validated. There was no control group to assess causality of longer-term outcomes. Tobacco-related behavior change was not measured, and the financial barriers to behavior change were mitigated due to study participation compensation.