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Respiratory Care in Primary Care Services
– A Survey in 9 Countries
Practical Approach to Lung Health
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CH-1211 Geneva 27
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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
World Health Organization
WHO/HTM/TB/2004.333
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
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© World Health Organization 2004
All rights reserved.
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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.
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ACKNOWLEDGEMENTS
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.
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
4.12
Age and respiratory conditions .................................................. 20
General distribution of respiratory conditions........................... 21
Distribution of ARI cases........................................................... 22
Distribution of CRD cases ......................................................... 23
Diagnosis of TB.......................................................................... 24
Overall drug prescription ........................................................... 27
Antibiotic prescription................................................................ 28
Prescription of drugs other than antibiotics............................... 30
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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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 disabilityadjusted 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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
drugs prescribed, antibiotics accounted, in general, for about 40%; the range
was: 28.4% in Argentina (with medical officers) to 67.0% in Côte d'Ivoire
(with medical officers).
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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.
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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
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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
remains to be determined.
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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 subpopulations 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
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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
probably lead to vertical health interventions within health systems. Such an
approach may not be viable in the longer term because of the need for
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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.
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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 firstfacility 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
aim of these sessions was to explain the objectives of the study, the use of
eligibility criteria, the disease categories based upon the International
Statistical Classification of Diseases and Related Health Problems, Tenth
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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.
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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 nonpneumonia 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.
The process of establishing pulmonary TB was analysed among respiratory
patients for whom sputum-smear examination was requested. Then, the
proportions of smear-positive and smear-negative cases among pulmonary
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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’s t-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.
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
health facility. Moreover, in all settings, this percentage was consistently
higher among females than among males (Tables 6A and 6B). Of this patient
sub-population, the percentage with respiratory symptoms varied widely,
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
requested for 875 patients who were not identified, in the medical
consultation, as suspected TB cases (Tables 20A and 20B). However, data
suggest that most of the patients categorized as TB suspects were referred to
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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).
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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.
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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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
Mediterranean climate. In addition, the study was undertaken in different
seasons. The study period from June to October is the rainy season in Côte
d’Ivoire, Guinea and Thailand, the period from March to June is the spring
16
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
17
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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).
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
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).
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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.
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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).
Proportionally very few pneumonia cases were identified among ARI cases
in all our surveys, irrespective of the type of health facilities (Tables 16A and
16B). The highest proportion, almost 9%, was reported in Côte d’Ivoire,
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which further supports the notion that in Côte d’Ivoire, and perhaps in
Guinea, there are relatively more patients with lower respiratory tract
symptoms and signs.
We did not succeed in identifying published data on ARI and its distribution
between AURI and ALRI among patients, aged five years and over, attending
PHC services in developing countries. According to the European
Respiratory Society, however, one-third of ARIs are ALRI cases and twothirds are AURI cases, which is similar to the results obtained here (9). It is
believed that in Europe 5–25% of ALRI are pneumonia cases (9) suggesting
that by extrapolation, 1.5–8.5% of all ARI cases are pneumonia cases. This is
almost identical to the range reported here.
4.7 Distribution of CRD cases
Approximately 60% of CRD patients were categorized as asthma cases,
accounting for almost 4% of all respiratory patients attending facilities with
nurses (Tables 15B and 16B). Given the small numbers of CRD cases
identified in Kyrgyzstan (4 cases) and Côte d’Ivoire (11 cases), it was not
possible to elucidate why very few asthma cases were reported in those
countries. In PHC centres with medical officers, overall proportions showed
that among CRDs, 55% were categorized as asthma cases and approximately
38% as CB/COPD cases (Table 15A), with these accounting for approximately 7% and 5% of the overall respiratory patients, respectively. It is not
known how the diagnoses of asthma and COPD were established by the
primary care physicians in these surveys. The diagnosis of asthma should, at
least, normally involve peak flow meter measurements (26, 27) and that of
COPD should be based on spirometric evidence. It is unlikely that such
equipment is widely available and used in medical primary care settings in
developing countries since, even in most developed countries, spirometry is
not commonly performed at this level. The large variation of asthma and
CB/COPD distribution among the study countries may be explained by the
absence of peak flow meters and/or spirometry as well as the influencing
variables discussed previously (case definitions, tobacco smoking, air
pollution, etc.). The high proportion of CB/COPD in the Kyrgyzstan survey
might be explained partially by the high frequency of tobacco consumption
(76) and the fact that the respiratory patients enrolled in the study were
relatively old (Tables 4A and 5A). Within the past decade, the international
medical community has been highly sensitized to asthma and this may have
influenced physicians to consider the diagnosis of asthma in their daily
practice in intermediate-income countries such as Argentina and Chile, where
asthma accounted for approximately 92% and 82% of CRD cases,
respectively. As there are no clear procedures and no appropriate treatment
available to manage asthma and COPD in PHC settings in many developing
countries, patients may consult private practitioners. Other patients may
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attend hospital emergency rooms when asthma attack or CODP exacerbation
occur and are, therefore, treated only for acute episodes without long-term
management of their disease. It is also thought that in most countries
throughout the world, even developed countries, asthma and COPD cases are
under-diagnosed (88, 89). Indeed, a study from Nijmegen, the Netherlands,
reported that about two-thirds of asthma and COPD cases existing in the
general population are not identified in general practice, chiefly asthma and
COPD cases with mild and moderate severity (90). Several studies from
developed countries have indicated that asthma is under-diagnosed in
adolescents (91), adults (92) and the elderly (93). It has also been reported
that asthma and COPD were identified in nearly 50% of patients who were
coughing for 2 weeks or more (88), but that COPD was particularly underdiagnosed in women (94). CP van Schayck has highlighted the role of the
under-presentation of respiratory symptoms by the patient in this underdiagnosis (92, 95).
Among CRD cases identified in PHC facilities staffed by nurses, the chronic
cough case category accounted for a variable proportion across the study
countries (Table 15B). Given the small number of those cases per country,
the system used to categorize the respiratory conditions in PHC centres with
nurses, and the potential weaknesses of referral systems within the PHC
network of the study countries, it is not possible to extrapolate on the
probable diagnoses of CRD included in the chronic cough category. Some
7% of CRD identified in PHC facilities with medical officers were not
categorized as either asthma or CB/COPD cases (Tables 15A). This group
included cases of suspected lung cancer, known bronchiectasis cases, known
TB sequelae cases and other respiratory cases. Some of these cases may have
presented isolated cough for weeks or months without any possibility of
establishing a precise diagnosis. Establishing a diagnosis in such patients is
beyond the resources available in PHC services of developing and even
developed countries. In developed countries, high-tech equipment is used in
tertiary health services to establish a diagnosis in these patients. Several
studies showed that the causes of isolated chronic cough are most frequently
cough variant-asthma, postnasal drip syndrome and gastro-oesophageal
reflux disease, and less frequently eosinophilic bronchitis, bronchiectasis or
chronic bronchitis (26, 96-99).
4.8 Diagnosis of TB
Overall, these surveys indicated that ancillary tests were requested for some
respiratory patients in PHC centres – approximately 18% and 16% in settings
with and without medical officers respectively (Tables 17A and 17B).
However, in PHC facilities with medical officers, the proportion of patients
for whom at least one test was requested varied among countries.
Paradoxically, the proportion of patients sent for ancillary tests was much
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higher in low-income countries (Kyrgyzstan and Nepal) than in middleincome countries (Argentina, Chile, Morocco and Thailand). There is no
clear explanation for the difference between these two categories of
countries. One wonders whether more tests are really needed in settings
where overcrowded and poorly equipped health facilities are common, and,
in many circumstances, these facilities are not easily accessible to
populations with limited resources. In Kyrgyzstan, ancillary tests were
requested in approximately two-thirds of the patients (Table 17A),
paradoxically nearly 70% of them (Table 13A) were categorized as ARI
cases, thus they had self-limiting respiratory conditions in most cases. This
suggests that such health care practices result in wasting of limited resources
and time for the patients, in non-necessary referral and in the placing of an
inappropriate workload on the referral health services.
The data generated in this study indicate that X-ray examinations are not
frequently requested for respiratory patients, since more than 80% of the
ancillary tests were laboratory-based (Tables 18A and 18B). Thus, X-ray
does not seem to be a major tool used in establishing a diagnosis in patients
with respiratory symptoms. This practice, however, may not constitute
deliberate behaviour from health workers, since in many developing
countries, X-ray equipment is not available in PHC facilities. In Kyrgyzstan,
among 1077 respiratory patients for whom at least one ancillary test was
requested, 865 (80.3%) were sent for chest X-ray examination (data not
shown).
Among laboratory tests requested for respiratory patients, sputum-smear
examinations accounted for a significant proportion, 66 and 29% in health
centres with and without medical officers, respectively (Tables 19A and
19B). However, in certain study settings, namely Chile, Kyrgyzstan and
Nepal, not all patients who were sent to the TB laboratory for microscopy
examination were considered beforehand, chiefly by physicians, to be TB
suspects (Tables 20A). This finding suggests that the criteria used to identify
TB suspect cases among respiratory cases, as defined by the international
community (100), are probably not thoroughly adopted, and therefore not
fully used on a routine basis by PHC workers in several developing countries.
It is also possible that among those who were categorized as TB suspect
cases, some of them were, in fact, not categorized according to the definition
recommended internationally and some were. This could result in
inappropriate workload in the TB laboratory and a poor TB case detection
sensitivity. Harries et al. reported, in one study in Malawi, that 62% of
patients who were identified as TB suspect cases in PHC facilities and sent
for sputum-smear examinations were, in fact, not TB suspects (101). Here, it
was demonstrated that in general, in both PHC settings, most of the patients
categorized as TB suspects were sent for sputum-smear examination (Tables
21A and 21B). In contrast, chest X-ray was requested for few patients except
in Kyrgyzstan and Nepal (with medical officer). Although sputum-smear
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examination has low sensitivity and high specificity compared with culture
(102), it remains, nevertheless, the major tool in TB case-finding among TB
suspect cases in developing countries. It is well established that smearpositive cases are those who disseminate TB bacilli in the community and
should be, accordingly, detected as a matter of priority. In good TB control
programme conditions, every TB suspect should give three sputum
specimens for direct microscopy. Detection of TB cases should not rely on
chest X-ray as this can be misleading and is more expensive than sputumsmear examination (101). A study has shown that nearly 75% of smearpositive and/or culture-positive TB patients had chest X-rays appearing nonconsistent with TB (103). The data collected in PHC facilities with nurses in
Côte d’Ivoire and Nepal indicates that 100% and 81.3% of patients for whom
sputum microscopy was requested were smear-positive, respectively. This is
unlikely to be accurate and suggests that the criteria used to identify TB
suspects were too restrictive (Table 22B). Among the other study countries,
there are tremendous variations in positivity rate in patients sent to the TB
laboratory for sputum-smear examination (Tables 22A and 22B). For
operational purposes, it is assumed by the international community that one
of 10 suspect TB cases is smear-positive (104). However, this is apparently
not quite uniform across countries throughout the world, as reported in these
surveys. In the United Republic of Tanzania for example, among 61 580 TB
suspects, approximately 19% were found to be smear-positive (105). These
variations may be explained by differences among countries in the quality of
the TB detection process within health services, as well as in TB burden.
Our data also show that some TB suspects may disappear during the process
of reference between the PHC facilities and the TB laboratory. Indeed, in
some study countries such as Guinea and Morocco, a non-negligible
proportion of suspected TB cases sent to laboratory for sputum-smear
examinations were subsequently not traceable in the TB laboratory registers
(Tables 22A and 22B). This may be explained by the poor accessibility to (or
the scarcity of) TB laboratories within the health system. However, in some
health system settings, a TB suspect case may be reassessed in the TB
laboratory and then considered as a non-TB suspect, thus her/his sputum
specimens are not examined. A recent study from Morocco showed that of 36
respiratory patients who were sent to TB laboratories by private practitioners,
two (6%) were reassessed as non-TB suspects and seven (19%) had chest Xray without sputum-smear examination, perhaps on the insistence of the
patients themselves or to decrease the workload in the TB laboratory (83).
An investigation undertaken in the United Republic of Tanzania, showed that
the required set of three sputum-smear examinations was not done in about
50% of suspect TB cases (105).
In most of the study settings, more than 75% of TB patients who were
identified in PHC facilities and prescribed anti-TB treatment were smearpositive, except in Nepal and Thailand (Tables 23A and 23B). This finding
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suggests that few patients identified as TB patients were wrongly put on antiTB treatment, since the confirmation rate by sputum-smear examination,
under TB control programme conditions, is usually between 65% and 80%
(4). It is assumed that the lower the bacteriological confirmation rate, the
higher the probability of treating false pulmonary TB cases. Among the total
number of respiratory patients attending PHC facilities, the proportion of TB
cases prescribed anti-TB treatment is, in general, very low (about 1.5%),
except in Côte d’Ivoire and Nepal, where TB burden is high (Tables 24A and
24B). The variation of this proportion among study countries could not be
explained only by differences in TB burden, but also by the procedures used
to set up the diagnosis of TB within health services.
4.9 Overall drug prescription
The overall proportion of respiratory patients who were prescribed drugs in
PHC facilities was approximately 95% (Tables 25A and 25B). This
percentage may appear high as many of them had minor health disorders.
However, this may also not reflect over-prescribing, especially if every
prescription includes a small number of drugs. Indeed in most study settings
the drug ratio per patient was below two, except in Guinea and Côte d’Ivoire
(Tables 29A and 29B). Surveys undertaken in 19 African, Asian, Latin
American and Caribbean countries showed that the number of drugs
prescribed per patient in PHC services was most often between 1.3 and 2.4
but that this ratio was as high as four in Ghana and Nigeria (106). Studies
involving patients attending PHC services for any reason attempted to
estimate the “correct” ratio and found 1.3 and 1.4 in Nepal (80) and 1.5 in
Yemen (107). However, inappropriate drug prescriptions exist all over the
world, in developing as well as in developed countries. In England and
Wales, general practitioners' prescriptions account for 10% of National
Health Service expenditure, of which £275 million could be saved if overprescribing was eliminated (108). Factors influencing, and motives leading
to, prescribing are multiple and complex; they have been extensively
analysed and reported in health literature. Indeed, satisfying patient drug
prescription demand or expectation is often reported by general practitioners
in order to preserve the doctor–patient relationship (109, 110). Also, authors
reported that the physician decision to prescribe was strongly influenced by
her/his perception of patients' expectations and to a lesser extent by ethnic
group, and the doctors' feeling of being pressurized (111). Furthermore, the
same authors reported that one-third of prescriptions were either not indicated
or not expected by the patients and 22% of prescriptions had no sound
medical indication. Other studies have suggested that doctors overestimate
the expectations of patients (112–114) and that drug prescription was 10
times higher among general practitioners who thought patients were
expecting prescription than those who did not (115). Data from the General
Household Survey in Great Britain suggested that patients with Indian or
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Pakistani background were more likely to receive medication than white or
West Indian patients (116). Doctors may prescribe in order to satisfy
demands from third parties, to reduce the consultation workload in the short
term, to show the patient she/he is not rejected or to avoid medico–legal
issues. However, their prescription may also be influenced by drug
companies, the educational level of patient or even worries about possible
assault by patient (109–110). It is also suggested that regular drug supply of
PHC facilities may increase prescription more than is needed (80), while
rationalized drug supply of PHC facilities may improve prescription (107).
4.10 Antibiotic prescription
Overall, about two-thirds of the respiratory patients enrolled in these surveys
were prescribed at least one antibiotic (excluding anti-TB drugs under TB
control programme conditions). Distribution by country showed that the
proportion of antibiotic prescription ranged from 85% in Guinea to 40% in
Kyrgyzstan (Tables 25A and 25B). In the health literature, it seems that it is
not easy to set up a standard proportion of antibiotic prescription among
respiratory patients that would be “acceptable”, because of the variations
among countries of disease morbidity and of treatment directives or practices.
However, the theoretical proportion of antibiotic prescription in PHC
attendees, irrespective of their age and their health care demand reasons, was
previously estimated at 25 and 22.7% in Nepal and in Yemen, respectively
(80, 107). Our findings suggest that antibiotic prescription is high, as 80% of
the patients presented with self-limiting conditions. Indeed, in most of the
study settings, more than 50% of ARI cases received antibiotics (Tables 26A
and 26B) while pneumonia cases which really needed such medication
accounted only for a tiny proportion (Tables 16A and 16B). In general,
nurses prescribed antibiotics as much as, if not more than, medical officers.
Lack of standardization in respiratory disease management and the quasi
absence of precise directives in prescription of drugs, chiefly antibiotics,
within PHC services lead to such abuses. Amoxicillin, co-trimoxazole and
penicillin or cyclines accounted for more than 80% of antibiotics prescribed
in these surveys (Tables 27A and 27B). This finding suggests that the
antibiotics prescribed remain, in most countries, within the Essential Drugs
List. Health workers may prescribe these because they are the only antibiotics
available within the PHC system or because they are financially accessible in
private pharmacies to patients who often have limited resources.
Cephalosporin, a relatively expensive drug, accounted for approximately
10% of antibiotics prescribed in settings with medical officers in Côte
d’Ivoire and Nepal (Table 27A). Such a prescription is rarely indicated for
respiratory conditions in PHC services; for example, in developed countries it
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
may be indicated as an alternative treatment for pneumonia cases managed at
home (9, 11). Anti-TB drugs were prescribed four and six times by
physicians outside the framework of a TB control programme in Kyrgyzstan
and Côte d’Ivoire, respectively. There is no clear explanation for which
respiratory conditions, besides TB, these anti-TB drugs were prescribed. This
suggests that misuse (perhaps sporadic) of anti-TB drugs might persist
alongside a well-established TB control programme.
Antibiotic prescription in patients with respiratory symptoms has been
extensively studied in developed countries. In England and Wales, general
practitioners annually prescribe over 30 million courses of antibiotics for
patients presenting with such symptoms (117), while in the USA, the
estimated cost of antibiotics prescribed for the common cold is US$ 37.5
million per year (118). Evidence has shown that many of these respiratory
conditions have viral rather than bacterial origins, and would therefore be
self-limiting (119, 120). Others studies found that antibiotics have virtually
no impact on patient re-attendance at primary care (121, 122) or on duration
of symptoms (123, 124). However, it is often reported that more than 75% of
patients with a lower respiratory tract disease receive antibiotic medication
from general practitioners (122, 125). Macfarlane et al. showed that, after
prescription, doctors thought antibiotics were definitely indicated in only
20% to 30% of cases and definitely not indicated in 20% of cases (125, 126).
This prescription rate seems to be influenced by the adult age of patient,
discoloured sputum production, chest signs and other factors (118, 122, 125,
127). The patient’s desire or pressure to receive antibiotics from physicians is
often highlighted as a factor that influences prescription (109, 125, 126).
Antibiotic prescription seems also to reflect the fact that physicians believe
that antibiotics will reduce re-consultation (125, 128). However, the
proportion of patients re-attending for the same respiratory complaints was
similar for general practitioners with different levels of antibiotic prescription
(122). As in our surveys, amoxicillin seems to be one of the most frequently
prescribed antibiotics for subjects with respiratory symptoms, with two
different authors reporting prescription rates of 58 and 54% (118, 121).
It is clear that antibiotic prescription is not only determined by clinical factors
but also by non-clinical factors. Guidelines regarding ALRI issued at national
and international levels are usually developed by specialists and are probably
more adapted to hospital settings than to primary care services (128). Their
elaboration should involve PHC workers and take into account the
consultation dynamic of the PHC setting as well as the relationships between
health workers and patients attending primary care and their communities.
Given the commonalties of respiratory symptoms, definition and
identification of clinical entities, to which antibiotics would be indicated in
the context of primary care, should be clearly formulated and used in PHC
settings. The absence of such standardization will perpetuate over-prescribing
resulting in i) re-consultation, related to drug side-effects (123) or to the
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
patient belief that her/his previous recovery was due to medication and that
the occurrence of new respiratory symptoms would need another prescription
(129); ii) emergence of antibiotic resistance; and iii) waste of financial
resources for the health care system and for patients.
4.11 Prescription of drugs other than antibiotics
Our data also showed that, other than antibiotics, aspirin and paracetamol
accounted for at least 45% of drugs prescribed in PHC facilities staffed by
nurses alone and more than 25% in most health centres with medical officers
(Tables 28A and 28B). These two medicines are on the Essential Drugs List,
and their low cost in most developing countries makes them available and
accessible for substantial parts of the populations.
Bronchial fluidifiers and antitussives did not represent a major proportion
among prescribed drugs, although they did account for one-quarter to onethird of prescriptions in Kyrgyzstan and Morocco. Even though their impact
in improving respiratory conditions is doubtful, their sales constitute an
enormous global market for pharmaceutical companies. Respiratory
symptoms, chiefly cough, are very common and are experienced by all
human beings at some point in their life; point prevalence of cough in the
population has been estimated to be between 5% and 40% (130). Many
people, all over the world, purchase fluidifiers or antitussives over the
counter in pharmacies or private shops without prescription.
Non-steroidal anti-inflammatory drugs accounted for different proportions of
the drugs prescribed in the study countries. They represented at least 10% in
Argentina, Morocco and Peru with variations possibly explained by various
medical practices and/or different accessibility to patients within health
systems.
In general, steroids accounted for a small proportion among prescribed drugs
other than antibiotics, except in Argentina, where they represented about
24%. It is not possible to explain such a high percentage, given that CRD
cases only accounted for 10% of respiratory patients, among whom 92%
were asthmatic cases (Table 16A). This might suggest that prescription of
steroids is higher than needed. Moreover, in our data sets, details on whether
steroids were prescribed in inhaler form were not collected. Inhaled
corticosteroids are currently highly recommended in persistent asthma cases
and in COPD cases showing a clear response to these drugs (26, 27, 30).
Although their utilization is cost-effective, inhaled corticosteroids are not
accessible for many patients because of their non-availability in many
countries, such as in Azerbaijan, Georgia and the Russian Federation (131),
and/or their prohibitive cost. However, it seems that they are more easily
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accessible in countries where generic versions are available, such as Poland
(131).
The proportion of bronchodilators among prescribed drugs other than
antibiotics also varied among the study settings. In Argentina and Chile, they
accounted for approximately 23% and 41%, respectively (Tables 28A), while
the proportion of CRD cases among respiratory patients was approximately
10% and 22%, respectively (Table 16A). Inhaled 2-agonists are highly
indicated in asthma and COPD management. More refined analysis of some
data sets showed that inhaled 2-agonists were little used in Guinea (with
nurses), Kyrgyzstan or Nepal, but accounted for 40%, 75% and 87% among
bronchodilators prescribed in Guinea (with medical officers), Morocco and
Chile, respectively (data not shown). Our findings suggest that inhaled 2agonists are still not widely used because, like inhaled corticosteroids, they
are non-available and expensive (132).
4.12 Management outcome
The treatment outcome of respiratory patients within one month of the
consultation varied among the study settings (Tables 31A and 31B). The
overall proportion of those who were still sick was 8.6% and 8.2% in PHC
facilities with and without medical officers, respectively. However, this
proportion was high in Kyrgyzstan (more than 50%) and Côte d’Ivoire (26%
and 35%). The frequency of CRD cases in health settings with nurses in those
two countries, which could have explained re-consultation, was low, since
their proportion among respiratory patients did not exceed 3% (Tables 13B).
In health centres with medical officers in Kyrgyzstan, the proportion of CRD
cases was approximately 25% (Tables 13A), but the proportion of those who
re-consulted was double. These findings suggest that a proportion of patients
previously categorized as ARI re-consulted. In Côte d’Ivoire (with medical
officers), CRD cases accounted for approximately 18% of cases, but 21% of
respiratory patients had been categorized as “others” which might probably
include patients with respiratory conditions not clearly identified. Study
findings showed that 5% to 20% of respiratory cases may re-consult for the
same complaints within one month of their first visit (121, 122). It is reported
that patients dissatisfied at the first visit tend to re-consult (125). As
discussed previously, getting further drug prescriptions may encourage
patients to re-consult for persisting minor symptoms that commonly occur
within the first two weeks. Macfarlane et al. pointed out that re-consultation
is a better indicator for assessing ALRI evolution than recovery rate, since it
measures “persisting and bothersome” symptoms (121).
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
There was a higher rate of lost-to-follow-up cases in health centres with
medical officers than those staffed by nurses alone, while the rate of patients
whose respiratory symptoms improved was lower in the former. This might
suggest that access for the patients is easier and the relationship between
health workers and the community is better in PHC facilities with nurses than
in PHC centres with medical officers.
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
5. CONCLUSION
Patients with respiratory symptoms account for a non-negligible proportion
of all PHC attendees. Our results, compared with the findings reported in the
literature, suggest that approximately 20% of subjects aged five years and
over who attend primary care services for any reason seek care for respiratory
symptoms. In general, most of these conditions tend to be categorized by
PHC workers as ARIs. Among respiratory patients aged five years and over,
the proportions of TB suspects and CRD cases, though less frequent than
ARI cases, vary widely across the study countries, as do the proportions of
asthma and COPD cases within the CRD group. These variations are
reflecting not only methodological issues inherent to the surveys themselves,
but also the lack of standardization in categorizing respiratory diseases by
health workers practicing in primary care settings. Differences in training
background between nurses and doctors involved in the surveys, exposure to
air pollution, tobacco smoking, climate and seasons during which surveys
were carried out also contribute to these variations. It is clear that in order to
have a fair insight into the distribution of respiratory conditions in a country,
all these issues should be defined and addressed in the study protocol before
undertaking such surveys.
The findings of this study also show that sputum-smear examination is the
most requested laboratory test for respiratory attendees in primary care
services. Although sputum-smear examination was requested for most of the
patients categorized as TB suspects, this test might also be requested, in some
developing countries, for respiratory cases who were not identified beforehand as such. This indicates that in some settings, there is a misuse, or
perhaps even a neglect of the usual criteria for identifying TB suspects in the
primary care setting. This situation should be urgently addressed to raise the
quality level of TB detection among respiratory patients and to address the
issues associated with TB laboratory workload. The lack of standardized
procedures for identifying and managing other nosological groups of respiratory conditions on a routine basis may heavily contribute to this misuse.
Comparisons between results reported here and those from the literature
suggest that, in general, drugs are not over-prescribed in PHC facilities.
However, they do point to an over-prescription of antibiotics given that most
respiratory conditions, as categorized by PHC workers in our surveys, are
self-limiting ARIs. When bronchodilators are prescribed, inhaled ß2-agonists
do not seem to be widely used in many developing countries probably
because of their high cost and/or their unavailability in primary care. In
general, steroids are prescribed infrequently, except in Argentina.
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Standardized procedures are needed to manage respiratory patients aged five
years of age and over in PHC settings. Such procedures should be based on a
syndromic approach to undertake health care actions for respiratory
conditions. This approach should establish clearly normalized management
procedures for the most frequent respiratory conditions encountered in PHC
settings, as well as define the conditions of their referral and counter-referral
between health care levels within health systems.
The two global targets, established by WHO and its partners, for TB control
through implementation of the DOTS strategy are to detect 70% of TB cases
present in the population and to cure 85% of them by the year 2005. DOTS
has been increasingly implemented worldwide since the mid-1990s. This
strategy has resulted in a high cure rate in countries where it is implemented
under programme conditions. However, TB detection remains below the
desired expectations in many country settings. Indeed, it is estimated that
only 32% of all estimated smear-positive TB cases are detected and treated
under DOTS conditions.
To tackle this deficiency, WHO has developed a multifaceted approach: i) the
Global DOTS Expansion to accelerate population DOTS coverage; ii) the
TB/HIV strategy to improve TB case detection in HIV patients and through
HIV/AIDS control efforts; and iii) the public–private mix project to involve
the private health sector in TB control efforts. In addition, weaknesses
inherent to health systems are highlighted as another reason why detection of
TB still remains low in many countries. To reduce these weaknesses, WHO
has developed: i) the Community DOTS strategy, aimed at involving
communities in the management of TB cases, and ii) the PAL strategy to
improve management of patients attending health facilities for respiratory
symptoms.
As a component of the Global DOTS Expansion Plan, PAL is a logical
extension in health settings with successful TB control programmes. The
objectives of this approach are i) to improve the quality of respiratory care on
an individual basis and ii) to improve the efficiency of respiratory service
delivery within the health system. PAL includes two basic components: i) the
standardization of respiratory case management through the development of
clinical practice guidelines, and ii) coordination among health care levels as
well as between the national TB programmes and general health services.
PAL focuses basically on priority respiratory diseases, namely TB, ARI,
asthma, and COPD in patients aged five years and over. To be successful in a
country or a region, the development and implementation of the PAL strategy
must be adapted to the epidemiological situation, the population age
distribution, the development level of the health system and the
socioeconomic situation.
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RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
It is expected that the PAL strategy will: i) secure and empower TB control in
changing health systems; ii) improve TB case detection and the quality of TB
diagnosis; iii) help countries to cope with ongoing health sector reform;
iv) provide operational indicators on TB detection within general health
services; v) improve planning and health resource management; vi) provide
an integrated health care delivery package to 20% or more of the patients in
PHC settings; vii) improve the health management information system;
viii) improve the referral system for respiratory conditions and TB;
ix) strengthen PHC services resulting in increasing PHC attendance by
patients with respiratory symptoms; x) reduce the prescription of drugs in
general and of antibiotics in particular; xi) strengthen the competence of PHC
workers and xii) contribute to strengthening the confidence of the population
in PHC services.
35
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
36
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prescribing strategies for sore throat: the medicalising effect of prescribing
antibiotics. British Medical Journal, 1997, 315:350–352.
130. Fuller RW, Jackson DM. Physiology and treatment of cough. Thorax,
1990, 45:425–430.
47
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
131. Aït-Khaled N, Enarson D, Bousquet J. Chronic respiratory diseases in
developing countries: the burden and strategies for prevention and
management. Bulletin of the World Health Organization, 2001, 79:971–979.
132. Parry E. Treating asthma in developing countries: a problem of
inaccessible unavailable essential medication. Thorax, 1997, 52:589.
48
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Annex A: Multicentre study of
respiratory disease management
in PHC facilities with medical
officers
49
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Annex A: Multicentre study of respiratory disease management in PHC
facilities with medical officers
Table 1A:
General characteristics of the multicentre study regarding respiratory disease
management in PHC facilities with medical officers.
Countries
Study period
No. of health
No. of symptomatic
facilities
respiratory patients
Thailand
–
3
2047
8.0%
Morocco (I)
–
3
1155
4.5%
Kyrgyzstan
–
3
1637
6.4%
Peru
May – Jul. 98
6
4005
15.6%
Argentina
–
8
3468
13.6%
Chile
Sep. – Nov.98
6
5912
23.1%
Nepal
–
2
925
3.6%
Côte d’Ivoire
Jun. – Jul. 99
4
247
1.0%
Guinea
Jul. – Sep. 99
9
2564
10.0%
Morocco (II)
10
3625
14.2%
OVERALL
54
25 585
100.0%
Table 2A:
Distribution, by sex, of the number of symptomatic respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
Females
Males
Total
Thailand
1047 51.1%
1000 48.9%
2047 100%
Morocco (I)
689 59.7%
466 40.3%
1155 100%
Kyrgyzstan
872 53.3%
765 46.7%
1637 100%
Peru
2147 53.7%
1848 46.3%
3995 100%
Argentina
2053 59.2%
1415 40.8%
3468 100%
Chile
3522 59.6%
2390 40.6%
5912 100%
Nepal
396 42.9%
528 57.1%
924 100%
Côte d’Ivoire
124 50.2%
123 49.8%
247 100%
Guinea
1317 51.4%
1247 48.6%
2564 100%
Morocco (II)
2243 61.9%
1382 38.1%
3625 100%
OVERALL
14 410 56.3%
11 164 43.7% *25 574 100%
50
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 3A:
Characteristics of age distribution, in years, by country.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
Range
Median age
Mean age (± SD)
Thailand
5 – 93
30
33.1
± 22.5
Morocco (I)
5 – 80
18
24.2
± 17.9
Kyrgyzstan
9 – 92
35
38.6
± 19.0
Peru
5 – 98
13
19.9
± 17.4
Argentina
NA
NA
NA
NA
Chile
5 – 99
16
29.1
± 24.9
Nepal
5 – 97
30
34.7
± 18.2
Côte d’Ivoire
NA
NA
NA
NA
Guinea
NA
NA
NA
NA
Morocco (II)
5 – 86
17
25.4
± 17.3
SD: standard deviation;
NA: not available.
Table 4A:
Comparison, by country, of age means between sexes.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
Mean age (± SD) Mean age (± SD)
p
in females
in males
Thailand
31.6
± 21.6
34.7
± 23.3
< 0.003
Morocco (I)
25.7
± 17.4
22.1
± 18.5
< 0.002
Kyrgyzstan
36.9
± 16.9
40.5
± 21.0
< 0.001
Peru
20.9
± 17.6
18.7
± 16.9
< 0.001
Argentina
NA
NA
NA
NA
Chile
32.3
± 24.4
25.4
± 25.0
< 0.001
Nepal
32.6
± 16.4
36.4
± 19.2
< 0.002
Côte d’Ivoire
NA
NA
NA
NA
Guinea
NA
NA
NA
NA
Morocco (II)
25.4
± 17.3
20.6
± 16.8
< 0.001
SD: standard deviation.
NA: not available.
51
p: p-value associated with Student’s t-test.
52
a
Age was not reported for 9 patients: one from Kyrgyzstan, 1 from Nepal and 7 from Peru.
Table 5A:
Age distribution, by country, of symptomatic respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
5 – 14 years
15 – 49 years
50 years
Thailand
617
30.1%
900
44.0%
530
25.9%
Morocco (I)
466
40.3%
542
46.9%
147
12.7%
Kyrgyzstan
4
0.2%
1195
73.0%
437
26.7%
Peru
2227
55.7%
1375
34.4%
396
9.9%
Argentina
1828
52.7%
1298
37.4%
342
9.9%
Chile
2826
47.8%
1570
26.6%
1516
25.6%
Nepal
111
12.0%
578
62.6%
235
25.4%
Côte d’Ivoire
35
14.2%
166
67.2%
46
18.6%
Guinea
1091
42.6%
1191
46.5%
282
11.0%
Morocco (II)
1528
42.2%
1692
46.7%
405
11.2%
OVERALL
10 733
42.0%
10 507
41.1%
4336
17%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Total
2047
1155
1636a
3998a
3468
5912
924
247
2564
3625
25 576
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 6A:
Proportion of patients aged five years and over among attendees who visited
health facilities for any reason.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries and sex No. of attendees
Total no. of
attendees with
of age 5
age 5
any age
Morocco (I)
Males
1501
2046
73.4%
Females
3221
3754
85.8%
Both
4722
5800
81.4%
Argentina
Males
3924
8784
44.7%
Females
6376
10863
58.7%
Both
10 300
19647
52.4%
Nepal
Males
3095
4158
74.4%
Females
3520
4093
86.0%
Both
6615
8251
80.2%
Guinea
Males
6050
11 498
56.2%
Females
9814
15 135
64.8%
Both
15 864
26 633
59.6%
Morocco (II)
Males
3758
5200
72.3%
Females
7 787
9196
84.7%
Both
11 545
14 396
80.2%
53
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 7A:
Proportion of symptomatic respiratory patients among attendees aged five
years and over who visited health facilities for any reason.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries and sex No. of respiratory
Total no. of
Proportion of
respiratory
patients of age 5 attendees of age
patients
5
Thailand
Males
1000
10 228
9.8%
Females
1047
12503
8.4%
Both
2047
22 731
9.0%
Morocco (I)
Males
466
1501
31.0%
Females
689
3221
21.4%
Both
1155
74 722
24.5%
Argentina
Males
1415
3924
36.1%
Females
2053
6376
32.2%
Both
3468
10 300
33.7%
Nepal
Males
528
3095
17.1%
Females
396
3520
11.3%
Both
924
6615
13.9%
Guinea
Males
1247
6050
20.6%
Females
1317
9814
13.4%
Both
2564
15 864
16.2%
Morocco (II)
Males
1390
3758
37.0%
Females
2235
7787
28.7%
Both
3625
11 545
31.4%
54
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 8A:
Proportion of patients aged five years and over among all respiratory patients
with any age.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries and sex No. of respiratory
Total no. of
Proportion of
respiratory
respiratory
patients of age 5
patients of any
patients of age 5
age
Morocco (I)
Males
466
767
60.8%
Females
689
971
71.0%
Both
1155
1738
66.5%
Argentina
Males
1415
4601
30.8%
Females
2053
4829
42.5%
Both
3468
9430
36.8%
Nepal
Males
528
801
66.0%
Females
396
531
74.6%
Both
924
1332
69.4%
Guinea
Males
1247
3709
33.6%
Females
1317
3873
34.0%
Both
2564
7582
33.8%
Morocco (II)
Males
1390
2447
56.8%
Females
2235
3300
67.7%
Both
3625
5747
63.1'%
55
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 9A:
Proportion of respiratory patients who previously visited health facilities in
the past month.
Multicentre study of respiratory disease management in primary health care
facilities with medical officers.
Countries
No. of
No. of respiratory patients
Percentage
respiratory
with at least one visit to
patients
health facilities during the
past month
Thailand
2047
440
21.5%
Morocco (I)
1155
10
0.9%
Kyrgyzstan
1631a
602
36.9%
Peru
4005
341
8.5%
Argentina
3468
63
1.8%
Chile
5912
670
11.3%
Nepal
435a
40
9.2%
Côte d’Ivoire
247
NA
NA
Guinea
2564
NA
NA
Morocco (II)
3625
169
4.7%
OVERALL
25 089a
2335
9.3%
a
The number of visits to health facilities in the past month was not reported for 496 patients: 6 from
Kyrgyzstan and 490 from Nepal.
NA: not available.
Table 10A:
Distribution of cumulative proportion of respiratory cases by patient delay for
consultation.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
No. of
Patients delay for consultation
patients
4 days
7 days
14 days
21 days
Morocco (I)
1147
NA
NA
NA
90.4%
Kyrgyzstan
1632
NA
NA
NA
72.7%
Peru
1273
NA
NA
NA
99.5%
Morocco (II)
3599
50%
75%
84%
91.0%
NA: not available.
56
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 11A:
Proportion of respiratory patients with at least one concomitant disease or
condition.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
No. of
No. of patients with
Percentage
respiratory
concomitant disease or
patients
condition
Thailand
2047
346
16.9%
Morocco (I)
1155
116
10.0%
Kyrgyzstan
1631a
445
27.3%
Peru
4005
256
6.4%
Argentina
3468
147
4.2%
Chile
5912
437
7.4%
Nepal
925
66
7.1%
Côte d’Ivoire
247
99
40.1%
Guinea
2564
NA
NA
Morocco (II)
3625
359
100%
OVERALL
23 015a
2271
9.9%
a
Concomitant disease or condition status unknown for 6 patients.
57
NA: not available.
58
TB: tuberculosis.
HBP: high blood pressure.
Table 12A:
Most frequent concomitant diseases or conditions in respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
No. of respiratory
Chronic
Old TB or Cardiovascular
Diabetes
patients with
respiratory current TB
disease
concomitant
disease
on
(including
disease or
treatment
HBP)
condition
Thailand
346
21.4%
4.3%
33.5%
Morocco (I)
116
10.3%
6.0%
14.7%
9.5%
Kyrgyzstan
445
8.8%
1.6%
29.2%
0.7%
Peru
256
10.2%
7.4%
Argentina
147
13.6%
0.0%
36.0%
Chile
437
11.2%
2.3%
52.7%
15.8%
Nepal
66
33.3%
16.7%
6.1%
6.1%
Côte
99
d’Ivoire
Guinea
Unknown
Morocco (II)
359
13.9%
8.9%
14.8%
7.5%
10.0%
14.8%
15.0%
4.3%
Digestive
disease
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
1.4%
5.3%
3.4%
13.0%
22.2%
Tobacco
100.0%
Malaria
59
TB: tuberculosis.
Table 13A:
Overall distribution of respiratory diseases by country.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
Total no. of
No. of acute
No. of TB suspect
No. of chronic
respiratory patients respiratory infection
cases
respiratory disease
cases
cases
Thailand
2047
100%
1727 84.4%
83
4.1%
229 11.2%
Morocco (I)
1155
100%
1034 89.5%
87
7.5%
29
2.5%
Kyrgyzstan
1637
100%
1137 69.5%
92
5.6%
408 24.9%
Peru
4005
100%
3070 76.7%
331
8.3%
87
2.2%
Argentina
3468
100%
3114 89.8%
1
0.0%
353 10.2%
Chile
5912
100%
4602 77.8%
0
0.0%
1308 22.1%
Nepal
925
100%
531 57.3%
169 18.3%
225 24.3%
Côte d’Ivoire
247
100%
125 50.6%
25 10.1%
44 17.8%
Guinea
2564
100%
2083 81.2%
210
8.2%
242
9.4%
Morocco (II)
3625
100%
3112 85.8%
276
7.6%
231
6.4%
OVERALL
25 585
100%
20 535 80.3%
1274
5.0%
3156 12.3%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
8
5
0
517
0
2
0
53
29
6
620
0.4%
0.4%
0.0%
12.9%
0.0%
0.0%
0.0%
21.1%
1.1%
0.2%
2.4%
Others
60
ALRI: acute lower respiratory infection.
Thailand
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
1727
1034
1137
3070
3114
4602
531
125
2083
3112
20 535
253
485
465
528
1082
1669
284
104
1634
1104
7608
14.6%
46.9%
40.9%
17.2%
34.7%
36.3%
53.5%
83.2%
78.4%
35.5%
37.0%
AURI: acute upper respiratory infection.
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
1474
549
672
2542
2032
2933
235
21
449
2008
12 915
85.4%
53.1%
59.1%
82.8%
65.3%
63.7%
44.3%
16.8%
21.5%
64.5%
62.9%
Table 14A:
Distribution, by country, of patients with acute respiratory infection.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
No. of acute respiratory
No. of ALRI cases
No. of AURI cases
infection cases
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
No. of non-categorized
cases of acute
respiratory infections
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
12
2.3%
0
0.0%
0
0.0%
0
0.0%
12
0.1%
61
CB/COPD: chronic bronchitis/chronic obstructive pulmonary disease.
Table 15A:
Distribution, by country, of chronic respiratory disease cases.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
No. of chronic
No. of asthma cases
No. of cases of
respiratory disease cases
CB/COPD/
Thailand
229
100%
52
22.7%
177
77.0%
Morocco (I)
29
100%
20
69.0%
9
31.0%
Kyrgyzstan
408
100%
42
10.3%
366
89.0%
Peru
87
100%
62
71.3%
25
28.7%
Argentina
353
100%
324
91.8%
29
8.0%
Chile
1308
100%
1068
81.7%
218
17.0%
Nepal
225
100%
14
6.0%
211
93.0%
Côte d’Ivoire
44
100%
10
22.0%
34
77.0%
Guinea
242
100%
40
16.0%
84
34.0%
Morocco (II)
231
100%
124
53.7%
33
14.3%
OVERALL
3156
100%
1756
55.4%
1186
37.6%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
No. of other chronic
respiratory diseases
0
0.0%
0
0.0%
0
0.0%
0
0.0%
0
0.0%
22
1.7%
0
0.0%
0
0.0%
118
48.8%
74
32.0%
214
6.8%
62
19 813 77.4%
83.9%
89.0%
64.8%
75.3%
87.5%
73.2%
54.4%
41.7%
722 2.8%
1718
1028
1061
3017
3036
4329
504
103
1932 75.4%
3085 85.1%
0.4%
0.5%
4.6%
1.3%
2.2%
4.6%
2.9%
8.9%
151 5.9%
27 0.7%
9
6
76
53
78
273
27
22
8.2%
7.6%
5.0%
210
276
1'274
83 4.1%
87 7.5%
92 5.6%
331 8.3%
1 0.0%
0 0.0%
169 18.3%
25 10.%
CB/COPD: chronic bronchitis/chronic obstructive pulmonary disease.
Thailand
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte
d’Ivoire
Guinea
Morocco
(II)
OVERALL
1756
40
124
6.9%
1.6%
3.4%
52 2.5%
20 1.7%
42 2.6%
62 1.5%
324 9.3%
1068 18.1%
14 1.5%
10 4.0%
1186
84
33
4.6%
3.3%
0.9%
177 8.6%
9 0.8%
366 22.4%
25 0.6%
29 0.8%
218 3.7%
211 22.8%
34 13.8%
Table 16A:
Overall distribution of respiratory disease cases by country.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
Acute respiratory infections
Chronic respiratory diseases
Cases of
Cases of nonSuspected
Asthma cases
CB/COPD
pneumonia
pneumonia
tuberculosis
cases
Other
chronic
cases
0 0.0%
0 0.0%
0 0.0%
0 0.0%
0 0.0%
22 0.4%
0 0.0%
0 0.0%
214 0.8%
118 4.6%
74 1.9%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
620
29
6
2.4%
1.1%
0.2%
8 0.4%
5 0.4%
0 0.0%
517 12.9%
0 0.0%
2 0.0%
0 0.0%
53 21.1%
Other
respiratory
conditions
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
25 585 100.0%
2564 100.0%
3625 100.0%
2047
1155
1637
4005
3468
5912
925
247
TOTAL
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 17A:
Distribution of the number of respiratory patients by country and ancillary test
request.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
No. of tests
At least one test
Total
requested
requested
Thailand
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
1890
1032
560
3568
3432
4771
386
NA
NA
3198
15 639
92.3%
89.4%
34.2%
89.1%
99.0%
80.7%
41.7%
157
123
1077
437
36
1141
539
NA
NA
427
3 510
88.2%
81.7%
NA: not available.
63
7.7%
10.6%
65.8%
10.9%
1.0%
19.3%
58.2%
11.8%
18.3%
2047
1155
1637
4005
3468
5912
925
NA
NA
3625
19 149
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 18A:
Distribution of the number of respiratory patients by country and type of
ancillary test request.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
Ancillary tests
Total
At least one lab.
Other ancillary test
test requested
requested
Thailand
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
a
119
105
943
428
6
NA
482
154
NA
308
2391
Côte d’Ivoire not included.
75.8%
85.4%
87.6%
97.9%
99.0%
38
18
134
9
30
NA
57
NA
NA
119
405
89.4%
b
72.1%
85.5%a
Chile not included.
64
24.8%
14.6%
12.4%
2.1%
1.0%
10.6%
27.9%
14.5%
157
123
1077
437
36
1141
539
NA
NA
427
2796
NA: not available.
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%b
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 19A:
Distribution, by country, of the number of sputum-smear examination
requests among patients for whom at least one laboratory test was requested.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
Laboratory tests
Total
Sputum-smear
Other lab. tests
examination
Thailand
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
a
Chile not included.
83
85
546
401
1
875
188
NA
NA
270
1576
69.7%
81.0%
57.9%
93.7%
16.7%
36
20
397
27
5
NA
294
NA
NA
38
815
39.0%
87.7%
66.0%a
b
Côte d’Ivoire not included.
65
30.3%
19.0%
42.1%
6.3%
83.3%
61.0%
12.3%
40.0%b
119
105
943
428
6
NA
482
154
NA
308
2391
NA: not available.
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 20A:
Distribution of sputum-smear examination indication by country and
tuberculosis suspect status.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
Sputum-smear examination
Total
Tuberculosis
Other respiratory
suspects
patients
Thailand
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
a
81
82
76
331
1
0
116
25
210
269
1166
Côte d’Ivoire not included.
97.6%
96.5%
13.9%
82.5%
100.0%
0.0%
61.7%
2
2.4%
3
3.5%
470 86.1%
70 17.5%
0
0.0%
875 100.0%
72 38.3%
NA
29 12.0%
1
0.4%
1522 56.6%
88.0%
99.6%
43.4%
NA: not available.
66
83
85
546
401
1
875
188
NA
239
270
2688
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%a
67
76
Kyrgyzstan
116
Nepal
269
1191
Morocco (II)
OVERALL
TRT: tuberculin reaction testing.
210
Guinea
25
0
Chile
Côte d’Ivoire
1
Argentina
331
82
Morocco (I)
Peru
81
Thailand
93.5%
97.5%
100.0%
100.0%
68.6%
0.0%
100.0%
100.0%
82.6%
94.3%
97.6%
0.0%
0.0%
0.0%
9.7%
4.5%
1.2%
52
3
0
0
4.1%
1.1%
0.0%
0.0%
35 20.7%
0
0
0
9
4
1
2
1
0
0
0
0
0
0
1
0
0
0.2%
0.4%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
1.1%
0.0%
0.0%
5
3
0
0
0
0
0
0
1
1
0
0.4%
1.1%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
1.1%
1.1%
0.0%
Table 21A:
Distribution of tuberculosis suspect patients by country and type of referral.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
X-ray with or
Hospital
Specialist
without TRT
0.0%
0.0%
0.0%
5.4%
0.0%
1.2%
24
0
0
0
1.9%
0.0%
0.0%
0.0%
18 10.7%
0
0
0
5
0
1
Other
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
1274
276
210
25
169
0
1
331
92
87
83
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Total
68
a
9
NA
NA
0
7
86
NA
75
9
199
13
31.4%
3.3%
11.4%
0.0%
0.8%
45.6%
10.6%
15.7%
66
80.7%
59 69.4%
NA
NA
1 100.0%
857 98.0%
92 48.9%
NA
122 51.0%
201 74.4%
1'398 80.3%
Kyrgyzstan and Peru are not included in the total.
Morocco (I)
Kyrgyzstan
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
Thailand
17.6%
21.8%
8.3%
0.0%
1.2%
5.3%
20.0%
4.8%
NA: not available.
17
NA
NA
0
11
10
NA
42
60
144
4
85
546a
401a
1
875
188
NA
239
270
1741
83
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Table 22A:
Outcome distribution, by country, in patients sent to tuberculosis laboratory.
Multicentre study of respiratory disease management in PHC facilities with medical
officers.
Countries
Sputum smear- Sputum smearUnknown
Total
positive
negative
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 23A:
Distribution, by country, of smear-positive and smear-negative pulmonary
tuberculosis cases.
Multicentre study of respiratory disease management in PHC facilities with
medical officers.
Countries
No. of smearNo. of smearTotal no. of
positive cases
negative cases
pulmonary
tuberculosis cases
Thailand
13
54.2%
11 45.8%
24 100%
Morocco (I)
9 100.0%
0
0.0%
9 100%
Kyrgyzstan
NA
NA
NA
Peru
NA
NA
NA
Argentina
0
0
0
Chile
7
77.8%
2 22.8%
9 100%
Nepal
86
68.3%
40 31.7%
126 100%
Côte d’Ivoire
24 100.0%
0
0.0%
24 100%
Guinea
75
86.2%
12 13.8%
87 100%
Morocco (II)
9
90.0%
1 10.0%
10 100%
OVERALL
223
77.2%
66 22.8%
289 100%
NA: not available.
69
70
925
247
2564
Nepal
Côte d’Ivoire
Guinea
a
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
0.2%
1.1%
2.9%
9.7%
9.3%
0.1%
0.0%
NA
NA
0.8%
0.6%
Proportion of
smear-positive
cases
0.0%
0.3%
0.5%
0.0%
4.3%
0.0%
0.0%
NA
NA
0.0%
0.5%
Proportion of
smear-negative
cases
The numbers of respiratory patients from Kyrgyzstan and Peru are not included in the total.
3625
19 943a
5912
Chile
Morocco (II)
OVERALL
3468
Argentina
1637
Kyrgyzstan
4005
1155
Peru
2047
Morocco (I)
Total no. of
respiratory patients
Thailand
Countries
Table 24A:
NA: not available.
0.3%
1.4%
3.4%
9.7%
13.6%
0.2%
0.0%
NA
NA
0.8%
Proportion of
number of
pulmonary
tuberculosis cases
1.2%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 25A:
Distribution, by country, of the number of respiratory patients who received
any drug prescription and of those who received antibiotic prescription.
Multicentre study of respiratory diseases management in PHC facilities with
medical officers.
Countries
Total no. of
No. of patients
No. of patients
respiratory patients
with drug
with antibiotic
prescription
prescription
Thailand
2047 100.0%
NA
1147 56.0%
Morocco (I)
1155 100.0%
1043 90.3%
770 66.7%
Kyrgyzstan
1637 100.0%
1598 97.6%
685 41.8%
Peru
Argentina
Chile
Nepal
Côte d’Ivoire
Guinea
Morocco (II)
OVERALL
a
4005
3468
5912
925
247
2564
3625
19 823a
21 870b
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
3843
NA
5685
751
NA
2436
3432
18 788
Thailand, Argentina and Côte d’Ivoire not included.
NA: not available.
71
b
96.0%
96.2%
81.2%
95.0%
94.7%
94.8%a
2502
NA
3396
609
NA
2196
2789
62.5%
57.4%
65.8%
85.6%
76.9%
14 094
Argentina et Côte d’Ivoire not included.
72
ALRI: acute lower respiratory infection.
CRD: chronic respiratory disease.
AURI: acute upper respiratory infection.
TB: tuberculosis.
NA: not available.
Others
Total
%.
No.
%.
25.0
8 56.0
0.0
5 66.7
41.8
72.3
517 62.5
NA
0.0
2 57.4
65.8
NA
NA
NA 85.6
0.0
6 76.9
69.8
538 61.6
NCARI: Non-categorized acute respiratory infection.
Table 26A:
Distribution, by country, of the proportion of respiratory cases’ categories with prescribed antibiotics.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
AURI
ALRI
NCARI
CRD
TB suspects
%.
No.
%.
No.
%.
No.
%.
No.
%.
No.
Thailand
58.8
1474 71.9
253
27.1
229 42.2
83
Morocco (I)
91.6
549 50.7
485
41.2
29 10.3
87
Kyrgyzstan
33.2
672 49.9
465
48.8
408 33.7
92
Peru
69.3
2542 66.7
528
12.2
87 0.0
331
Argentina
NA
NA
NA
NA
Chile
58.2
2933 83.5
1669
22.6
1308
Nepal
94.5
235 77.8
284 91.7
12 63.1
225 7.7
169
Côte d’Ivoire
NA
NA
NA
NA
Guinea
NA
NA
NA
NA
Morocco (II)
86.0
2008 73.1
1104
45.5
231 54.7
276
OVERALL
67.3
10 413 71.7
4788 91.7
12 32.9
2517 23.0
1038
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
2564
3625
21 870
5912
925
No.
2047
1155
1637
4005
73
Sulfamides
Quinolones
Anti-TB
Others
Total
Lincomycin
Oxacillin
Ampicillin
Penicillin
Macrolide
Cyclines
Antibiotics
Amoxicillin
Table 27A:
Distribution, by country, of antibiotic prescription categories.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
74
NSAI: non-steroidal anti-inflammatory drugs.
Table 28A:
Distribution, by country, of the prescription of drugs other than antibiotics.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
Morocco
Peru
Argentina
Chile
Nepal
(I)
Drug
%
%
%
%
%
%
categories
Aspirin
456 34.3 440 26.1 1798 55.5 942 28.9 810 18.9 250 68.3
Fluidifier or
431 32.4 529 31.3 161 5.0
67 2.1 555 13.0 23 6.3
antitussive
NSAI
154 11.6
0 0.0 520 16.0 323 9.9 265 6.2
3 0.8
Vitamins
110 8.3 171 10.1
0 0.0
0 0.0
0 0.0
7 1.9
137 10.3 139 8.2
78 2.4 418 12.8 395 9.2 36 9.8
18 1.4 187 11.1 228 7.0 742 22.7 1770 41.4 34 9.3
Steroids
4 0.3
33 2.0 244 7.5 765 23.5
65 1.5
2 0.5
0 0.0
0 0.0
0 0.0
0 0.0
0 0.0
0 0.0
Others
19 1.4 189 11.2 213 6.6
5 0.0 416 9.7 11 3.0
Total
1329 100 1688 100 3242 100 3262 100 4276 100 366 100
1740 7.8
435
1.9
1505 6.7
3173 14.2
1259 5.6
1808 8.1
1022 4.6
22 322 100
%
0 0.0
2 0.0 473 11.5
7 7.9
0 0.0 140 3.4
0 0.0
9 0.2 293 7.1
0 0.0
39 1.0 155 3.8
0 0.0
15 0.4 131 3.2
3 3.4 1805 45.5
0 0.0
15 16.9
42 1.1 112 2.7
89 100 3968 100 4102 100
Morocco
(II)
%
8492 38.0
2888 12.9
%
Guinea
54 60.7 2039 51.4 1703 41.5
10 11.2
17 0.4 1095 26.7
Côte
d’Ivoire
%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
75
5912
925
247
2564
Chile
Nepal
Côte d’Ivoire
Guinea
*Thailand not included.
NA: not available.
23 538a
3625
25 585
3468
Argentina
Morocco (II)
OVERALL
4005
1637
Kyrgyzstan
Peru
1155
Morocco (I)
6895
37 728a
6224
270
974
7937
4557
6169
2591
2111
1.9:1
1.6:1
2.4:1
1.1:1
1.1:1
1.3:1
1.3:1
1.5:1
1.6:1
18:1
2793
16 571
2256
181
608
3661
1295
2927
903
782
0.8:1
0.6:1
0.9:1
0.7:1
0.7:1
0.6:1
0.4:1
0.7:1
0.6:1
0.7:1
4102
22 322a
3968
89
366
4276
3262
3242
1688
1329
1.1:1
1.0:1
1.5:1
0.4:1
0.4:1
0.7:1
0.9:1
0.8:1
1.0:1
1.2:1
Table 29A:
Distribution, by country, of prescribed drug ratio per respiratory patient.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
Total no. of
Total no. of prescribed
No. of prescribed
No. of prescribed
respiratory patients
drugs and drug ratio
antibiotics and
drugs other than
per respiratory patient
antibiotic ratio per
antibiotics and their
respiratory patient
ratio per respiratory
patient
Thailand
2047
NA
1165
0.6:1
NA
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 30A:
Distribution, by country, of antibiotic proportion among overall drugs
prescribed to respiratory patients.
Multicentre study of respiratory disease management in PHC facilities
with medical officers.
Countries
Total no. of
No. of prescribed
Proportion of
prescribed drugs
antibiotics
prescribed
antibiotics
a
Thailand
NA
1165
NA
Morocco (I)
2111
782
37.0%
Kyrgyzstan
2591
903
34.9%
Peru
6169
2927
47.4%
Argentina
4557
1295
28.4%
Chile
7937
3661
46.1%
Nepal
974
608
62.4%
Côte d’Ivoire
270
181
67.0%
6224
2256
36.2%
6895
37 728
2793
15 406a
40.0%
40.8%
Guinea
Morocco (II)
OVERALL
a
Thailand not included.
NA: not available.
76
77
Table 31A:
Outcome, within the month following the visit to health facility, of respiratory patient management.
Multicentre study of respiratory disease management in PHC facilities with medical officers.
Countries
Lost to follow-up
Improvement or
Still sick
Diagnosis change
cure
Thailand
1865 91.1%
96
4.7%
56
2.7%
30 1.5%
Morocco (I)
974 84.1%
140 12.1%
41
3.5%
0 0.0%
Kyrgyzstan
95
5.8%
493 30.1%
970 59.3%
0 0.0%
Peru
2136 53.3%
1448 36.2%
421 10.5%
0 0.0%
Argentina
3426 98.8%
3
0.1%
39
1.1%
0 0.0%
Chile
5246 88.7%
592 10.0%
6
0.1%
47 0.8%
Nepal
221 23.9%
399 43.1%
116 12.5%
184 19.9%
Côte d’Ivoire
180 72.3%
1
0.4%
65 26.3%
0 0.0%
Guinea
809 31.6%
1360 53.0%
395 15.4%
0 0.0%
Morocco (II)
3309 91.3%
158
4.4%
99
2.7%
48 1.3%
OVERALL
18 261 71.4%
4690 18.3%
2208
8.6%
309 1.2%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
0
0
79
0
0
21
5
1
0
11
117
0.0%
0.0%
4.8%
0.0%
0.0%
0.4%
0.5%
0.4%
0.0%
0.3%
0.5%
Others
2047
1155
1637
4005
3468
5912
925
247
2564
3625
25 585
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
TOTAL
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
78
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Annex B: Multicentre study of
respiratory disease management
in PHC facilities with nurses
79
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Annex B: Multicentre study of respiratory disease management in PHC
facilities with nurses
Table 1B:
General characteristics of the multicentre study regarding respiratory diseases
management in PHC facilities with nurses.
Countries
Study period
No. of health
No. of symptomatic
facilities
respiratory patients
Thailand
2
390
10.2%
Aug. Oct. 97
Kyrgyzstan
2
131
3.4%
Nepal
5
594
14.0%
Apr. Jun. 99
Côte d’Ivoire
2
470
12.3%
Jun. Jul. 99
Guinea
11
2289
60.0%
Jul. Sep. 99
OVERALL
22
3814
100.0%
Table 2B:
Distribution, by sex, of the number of symptomatic respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Females
Males
Total
Thailand
212 54.4%
174 45.6%
390 100%
Kyrgyzstan
77 58.8%
54 41.2%
131 100%
Nepal
244 45.7%
290 54.3%
534 100%
Côte d’Ivoire
303 64.5%
167 35.5%
470 100%
Guinea
1234 53.9%
1055 46.1%
2289 100%
OVERALL
2070 54.3%
1744 45.7%
3814 100%
80
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 3B:
Characteristics of age distribution, in years, by country.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Range
Median age
Mean age (± SD)
Thailand
5 – 95
30
31.5
± 20.4
Kyrgyzstan
14 – 78
33
37.2
± 14.8
Nepal
5 – 90
30
33.7
± 20.5
Côte d’Ivoire
NA
NA
NA
NA
Guinea
NA
NA
NA
NA
SD: standard deviation.
NA: not available.
Table 4B:
Comparison, by country, of age means between sexes.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Mean age (± SD) Mean age (± SD)
p
in females
in males
Thailand
32.4
± 20.6
30.5
± 20.2
0.64
Kyrgyzstan
37.1
± 15.0
37.4
± 14.7
0.91
Nepal
32.9
± 20.6
34.5
± 20.4
0.358
Côte d’Ivoire
NA
NA
NA
NA
Guinea
NA
NA
NA
NA
SD: standard deviation.
NA: not available.
81
p: p-value associated with Student’s t-test.
82
Table 5B:
Age distribution, by country, among symptomatic respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
5 – 14 years
15 – 49 years
Thailand
108
27.7%
203
52.1%
Kyrgyzstan
1
0.8%
104
79.4%
Nepal
118
22.1%
259
48.5%
Côte d’Ivoire
18
3.8%
437
93.0%
Guinea
1126
49.2%
906
39.6%
OVERALL
1371
35.9%
1909
50.1%
50 years
79
20.3%
26
19.8%
157
29.4%
15
3.2%
257
11.2%
534
14.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Total
390
131
534
470
2289
3814
100%
100%
100%
100%
100%
100%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 6B:
Proportion of patients of five years of age and over among attendees who
visited health facilities for any reason.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries and sex No. of attendees
Total no. of
Proportion of
attendees of any
attendees of age
of age 5
age
5
Nepal
Males
2604
3411
76.3%
Females
3719
4425
84.0%
Both
6323
7836
80.7%
Guinea
Males
5323
10 510
50.6%
Females
7510
12 481
60.2%
Both
12 833
22 991
55.8%
83
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 7B:
Proportion of symptomatic respiratory patients among attendees aged five
years and over who visited health facilities for any reason.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries and sex No. of respiratory
Total no. of
Proportion of
respiratory
patients of age 5 attendants of age
patients
5
Thailand
Males
178
568
31.3%
Females
212
667
31.8%
Both
390
1235
31.6%
Nepal
Males
293
2604
11.3%
Females
242
3719
6.5%
Both
535
6323
8.5%
Guinea
Males
1056
5323
19.8%
Females
1234
7510
16.4%
Both
2290
12 833
17.8%
84
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 8B:
Proportion of patients aged five years and over among all respiratory patients
of any age.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries and sex No. of respiratory
Total no. of
Proportion of
respiratory
respiratory
patients of age 5
patients of any
patients of age 5
age
Nepal
Males
293
418
70.1%
Females
242
338
71.6%
Both
535
756
70.8%
Guinea
Males
1056
3691
28.6%
Females
1234
3526
35.0%
Both
2290
7217
31.7%
85
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 9B:
Proportion of respiratory patients who previously visited health facilities in
the last month.
Multicentre study of respiratory disease management in primary health care
facilities with nurses.
Countries
No. of
No. of respiratory patients
Percentage
respiratory
with at least one visit to
patients
health facilities during the
last month
Thailand
390
82
21.0%
Kyrgyzstan
131
30
22.9%
Nepal
534
46
8.6%
Côte d’Ivoire
470
33
7.0%
Guinea
2289
NA
NA
OVERALL
1525a
191
12.5%
a
Guinea not included.
NA: not available.
Table 10B:
Distribution of cumulative proportion of respiratory cases by patient delay for
consultation.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
No. of
Patients delay for consultation
patients
4 days
7 days
14 days
21 days
Thailand
390
NA
NA
NA
99.2%
Kyrgyzstan
131
NA
NA
NA
95.4%
NA: not available.
86
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 11B:
Proportion of respiratory patients with at least one concomitant disease or
condition.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
No. of
No. of patients with
Percentage
respiratory
concomitant disease or
patients
condition
Thailand
390
8
2.1%
Kyrgyzstan
128a
19
14.8%
Nepal
534
31
5.8%
Côte d’Ivoire
470
414
88.1%
Guinea
2289
NA
NA
b
OVERALL
1522
472
**31.0%
a
b
Guinea not included.
NA: not available.
87
88
TB: tuberculosis.
HBP: high blood pressure.
Table 12B:
Most frequent concomitant diseases or conditions in symptomatic respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
No. of respiratory
Chronic
Old TB or Cardiovascular
Diabetes
patients with
respiratory current TB
disease
concomitant disease
disease
on
(including
or condition
treatment
HBP)
Thailand
8
37.5%
Kyrgyzstan
19
5.3%
21.1%
10.5%
Nepal
31
74.2%
6.5%
6.5%
414
Guinea
Unknown
12.9
Digestive
disease
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
42.1%
Tobacco
100.0%
Malaria
89
TB: tuberculosis.
Table 13B:
Overall distribution of respiratory diseases by country.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
Total no. of
No. of acute
No. of TB suspect
respiratory patients respiratory infection
cases
cases
Thailand
390
100%
370 94.9%
0
0.0%
Kyrgyzstan
131
100%
126 96.2%
1
0.8%
Nepal
534
100%
265 49.6%
92 17.2%
Côte d’Ivoire
470
100%
434 92.3%
24
5.1%
Guinea
2289
100%
2167 94.9%
48
2.1%
OVERALL
3814
100%
3362 88.1%
165
4.3%
No. of chronic
respiratory disease
cases
20
5.1%
4
3.0%
120 22.5%
11
2.3%
71
3.1%
226
5.9%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
0
0
57
1
3
61
0.0%
0.0%
10.7%
0.2%
0.2%
1.6%
Others
90
ALRI: acute lower respiratory infection.
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
370
126
265
434
2167
3362
0
6
81
270
494
851
0.0%
4.8%
30.6%
62.2%
22.8%
25.3%
AURI: acute upper respiratory infection.
100%
100%
100%
100%
100%
100%
Table 14B:
Distribution, by country, of patients with acute respiratory infection.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
No. of acute respiratory
No. of ALRI cases
infection cases
370
120
150
164
1673
2477
100.0%
95.2%
56.6%
37.8%
77.2%
73.7%
No. AURI of cases
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
No. of non-categorized
cases of acute
respiratory infections
0
0.0%
0
0.0%
34
12.8%
0
0.0%
0
0.0%
34
1.0%
91
CB/COPD: chronic bronchitis/chronic obstructive pulmonary disease.
Table 15B:
Distribution, by country, of chronic respiratory disease cases.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
No. of chronic
No. of asthma cases
No. of CB/COPD cases
respiratory disease cases
Thailand
20
100%
19
95.0%
1
5.0%
Kyrgyzstan
4
100%
0
0.0%
4
100.0%
Nepal
120
100%
67
55.8%
53
44.2%
Côte d’Ivoire
11
100%
2
18.2%
9
81.2%
Guinea
71
100%
49
69.0%
22
31.0%
OVERALL
226
100%
137
60.6%
89
39.4%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
92
a
Overall number of acute respiratory infection cases;
b
Overall proportion of acute respiratory infection cases.
Table 16B:
Overall distribution of respiratory disease cases by country.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
Acute respiratory infections
Chronic respiratory diseases
Other
Cases of
Cases of nonSuspects of
Asthma cases Chronic cough respiratory
conditions
pneumonia
pneumonia
tuberculosis
cases
Thailand
0 0.0%
370 94.9%
0 0.0%
19 4.9%
1 0.3%
0
0.0%
Kyrgyzstan
1 0.8%
125 95.4%
1 0.8%
0 0.0%
4 3.0%
0
0.0%
Nepal
6 1.1%
259 48.5%
92 17.2%
67 12.5%
53 9.9%
57 10.7%
Côte
The number of pneumonia
24 5.1%
2 0.4%
9 1.9%
1
0.2%
d’Ivoire
cases is unknown; but, the
number of acute respiratory
infection cases is: 434 (92.3%)
Guinea
The number of pneumonia
48 2.1%
49 2.1%
22 1.0%
3
0.1%
cases is unknown; but, the
number of acute respiratory
infection cases is: 2167
(94.7%)
OVERALL
3362a
88.1%b
165 4.3%
137 3.6%
89 2.3%
61 1.6%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
100.0%
100.0%
100.0%
100.0%
3814 100.0%
2'289 100.0%
390
131
534
470
TOTAL
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 17B:
Distribution of the number of respiratory patients by country and ancillary
test request.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
No test requested
At least one test
Total
requested
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
390 100.0%
106
80.9%
425
79.6%
365
77.7%
NA
1286
84.3%
0
25
109
105
NA
239
NA: not available.
93
0.0%
20.1%
20.4%
22.3%
15.6%
390
131
534
470
NA
1525
100.0%
100.0%
100.0%
100.0%
100.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 18B:
Distribution of the number of respiratory patients by country and type of
ancillary test request.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Ancillary tests
Total
At least one lab.
Other ancillary test
test requested
requested
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
a
0
0.0%
5
20.0%
109 100.0%
NA
NA
114
79.3%
0
20
0
NA
NA
20
Côte d’Ivoire not included in the total.
80.0%
80.0%
0.0%
20.7%
NA: not available.
94
0
25
109
105
NA
134
100.0%
100.0%
100.0%
100.0%
100.0%a
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 19B:
Distribution, by country, of the number of sputum-smear examination
requests among patients for whom at least one laboratory test was requested.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Lab. tests
Total
Sputum-smear
Other laboratory
examination
tests
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
0
1
32
NA
NA
33
0
4
77
NA
NA
81
20.0%
29.4%
29.0%
NA: not available.
95
80.0%
70.6%
71.0%
0
5
109
NA
NA
114
100.0%
100.0%
100.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Table 20B:
Distribution of sputum-smear examination indication by country and
tuberculosis suspect status.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Sputum-smear examination
Total
Tuberculosis
Other respiratory
suspect
patients
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
a
0
1
31
24
48
32a
0
0
1
NA
NA
1
100.0%
96.9%
97.0%
Côte d’Ivoire and Guinea not included.
0.0%
3.1%
3.0%
NA: not available.
96
0
1
32
NA
NA
33a
100.0%
100.0%
100.0%a
97
31
24
Nepal
Côte d’Ivoire
104
TRT: tuberculin reaction testing.
OVERALL
48
1
Kyrgyzstan
Guinea
0
Thailand
63.0%
100.0%
100.0%
33.7%
100.0%
1
0
0
1
0
0
1.6%
0.0%
0.0%
1.1%
0.0%
0
0
0
0
0
0
0.0%
0.0%
0.0%
0.0%
0.0%
0
0
0
0
0
0
0.0%
0.0%
0.0%
0.0%
0.0%
Table 21B:
Distribution of tuberculosis suspect patients by country and type of referral.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
X-ray with or
Hospital
Physician
without TRT
0.0%
0.0%
0.0%
47 28.5%
0
0
47 51.1%
0
0
Other
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
13
0
0
13
0
0
0.0%
7.9%
0.0%
0.0%
14.1%
None
165
48
24
92
1
0
100%
100%
100%
100%
100%
Total
98
0
0
26
24
5
55
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
10.4%
52.4%
0.0%
81.3%
0
5
0
24
29
0
0.0%
15.6%
0.0%
50.0%
27.6%
1
1
0
19
21
0
3.1%
0.0%
39.6%
20.0%
1
32
24
48
105
0
100.0%
100.0%
100.0%
100.0%
100.0%
Table 22B:
Outcome distribution, by country, in patient sent to Tuberculosis laboratory.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
Sputum smear- Sputum smearUnknown
Total
positive
negative
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
99
Table 23B:
Distribution, by country, of smear-positive and smear-negative pulmonary
tuberculosis cases.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
No. of smear
No. of smear
Total no. of
positive cases
negative cases
pulmonary
tuberculosis cases
Thailand
0
0
0
Kyrgyzstan
0
0
0
Nepal
26 96.3%
1 3.7%
27 100.0%
Côte d’Ivoire
24 100.0%
0 0.0%
24 100.0%
Guinea
5 100.0%
0 0.0%
5 100.0%
OVERALL
55 98.2%
1 1.8%
56 100.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
100
131
534
470
2289
3814
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
OVERALL
100.0%
100.0%
100.0%
100.0%
100.0%
0.2%
1.4%
5.1%
4.9%
0.0%
0.0%
0.0%
0.0%
0.2%
0.0%
0.2%
1.5%
5.1%
5.1%
0.0%
Table 24B:
Distribution, by country, of the proportions of smear-positive and of smear-negative pulmonary
tuberculosis among overall respiratory patients.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
Total no. of
Proportion of no.
Proportion of no.
Proportion of total
respiratory patients
smear-positive
smear-negative
no. of pulmonary
cases
cases
tuberculosis cases
Thailand
390 100.0%
0.0%
0.0%
0.0%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
101
a
470
2289
2954a
3344b
100.0%
100.0%
100.0%
100.0%
Thailand and Côte d’Ivoire not included;
Côte d’Ivoire
Guinea
OVERALL
b
99.7%
98.0%a
Côte d’Ivoire not included.
NA
2282
2895
b
84.6%
NA: not available.
2496
NA
1937
Table 25B:
Distribution, by country, of the number of respiratory patients who received
any drug prescription and of those who received antibiotic prescription.
Multicentre study of respiratory disease management in PHC facilities with
nurses.
Countries
Total no. of
No. of patients
No. of patients
respiratory patients
with drug
with antibiotic
prescription
prescription
Thailand
390 100.0%
NA
180 46.2%
Kyrgyzstan
131 100.0%
130 99.2%
51 38.9%
Nepal
534 100.0%
483 90.4%
328 61.4%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
102
ALRI: acute lower respiratory infection;
CRD: chronic respiratory disease;
AURI: acute upper respiratory infection;
TB: tuberculosis.
NA: not available.
59.6
NA
NA
59.6
57
57
Others
%.
No.
NCARI: non categorized acute respiratory infection;
Table 26B:
Distribution, by country, of the proportion of respiratory case categories with prescribed antibiotics.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
AURI
ALRI
NCARI
CRD
TB suspects
%.
No.
%.
No.
%.
No.
%.
No.
%.
No.
Thailand
47.3 370
25.0
20
Kyrgyzstan
36.7 120
66.7
6
75.0
4
0.0
1
Nepal
74.0 150
93.8
81
91.2
34
47.5 120
20.7
92
Côte d’Ivoire
NA
NA
NA
NA
NA
Guinea
NA
NA
NA
NA
NA
OVERALL
51.6 640
98.7
87
91.2
34
44.4 144
20.5
93
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
Total
%.
No.
46.2
390
38.9
131
61.4
534
NA
84.6 2289
53.0
3344
103
Table 27B:
Distribution, by country, of antibiotic prescription categories.
Multicentre study of respiratory disease management in PHC facilities with medical nurses.
Countries
Thailand
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
Antibiotics
%
%
%
%
%
15
8.3
38
64.4
170
51.8
0
0.0
1929
86.9
75
41.4
0
0.0
92
28.0
395
63.3
78
3.5
0
0.0
0
0.0
59
18.0
4
0.6
192
8.7
0
0.0
0
0.0
0
0.0
202
43.0
6
0.3
81
44.8
20
33.9
2
0.6
0
0.0
11
0.5
0
0.0
0
0.0
3
0.9
20
3.2
3
0.1
10
5.5
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
3
0.5
0
0.0
0
0.0
0
0.0
1
0.3
0
0.0
0
0.0
0
0.0
1
0.0
0
0.0
0
0.0
0
0.0
0
0.0
0
0.0
1
0.3
0
0.0
0
0.0
Total
181 100.0
0 100.0
328 100.0
624 100.0
2219 100.0
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
OVERALL
%
2152
63.1
640
18.8
255
7.5
208
6.1
114
3.3
26
0.8
10
0.3
3
0.1
1
0.0
1
0.0
1
0.0
3411 100.0
104
NSAI: non-steroidal anti-inflammatory drugs.
Table 28B:
Distribution, by country, of the prescription of drugs other than antibiotics.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
Kyrgyzstan
Nepal
Côte d’Ivoire
Guinea
Drug categories
%
%
%
%
Aspirin
82
92.1
283
52.9
259
44.9
2119
49.2
Fluidifier or
3
3.4
38
7.1
117
20.3
0
0.0
antitussive
NSAI
0
0.0
3
0.8
0
0.0
0
0.0
Vitamins
0
0.0
19
3.6
0
0.0
0
0.0
Decongestants
0
0.0
71
13.3
0
0.0
0
0.0
Bronchodilatators
4
4.5
101
18.9
0
0.0
60
0.0
Steroids
0
0.0
1
0.2
0
0.0
1
1.4
Antimalarials
0
0.0
0
0.0
201
34.8
1979
0.0
Others
0
0.0
22
4.1
0
0.0
151
45.9
Total
89 100.0
538 100.0
577 100.0
4310 100.0
3
19
71
165
2
2180
173
5514
0.1
0.3
1.3
3.0
0.0
39.5
3.1
100.0
OVERALL
%
2743
49.7
158
2.9
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
105
6529
*8741
1201
Thailand not included in the total number of respiratory patients.
3424a
2289
3814
Guinea
OVERALL
a
470
Côte d’Ivoire
863
2.9:1
2.6:1
2.6:1
1.6:1
NA: not available.
2219
3411
624
328
1.0:1
0.9:1
1.3:1
0.6:1
4310
*5511
577
535
534
Nepal
0.5:1
89
59
NA
1.1:1
131
Kyrgyzstan
148
Table 29B:
Distribution, by country, of prescribed drug ratio per respiratory patient.
Multicentre study of respiratory disease management in PHC facilities with nurses
Countries
Total no. of
Total no.of prescribed
No. of prescribed
respiratory patients
drugs and drug ratio
antibiotics and
per respiratory patient
antibiotic ratio per
respiratory patient
Thailand
390
NA
181
0.5:1
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
:1
1.9:1
1.6:1
1.2:1
1.0:1
0.7:1
106
1201
6529
8741
Côte d’Ivoire
Guinea
OVERALL
Thailand not included.
863
Nepal
a
148
Kyrgyzstan
NA: not available.
2219
3230a
624
328
59
34.0%
36.9%a
52.0%
38.0%
39.9%
Table 30B:
Distribution, by country, of antibiotic proportion among overall drugs
prescribed to respiratory patients.
Multicentre study of respiratory disease management in PHC facilities
with nurses.
Countries
Total no.of
No. of prescribed
Proportion of
prescribed drugs
antibiotics
prescribed
antibiotics
Thailand
NA
181
NA
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
107
Table 31B:
Outcome, within the month following the visit to health facility, of respiratory patient management.
Multicentre study of respiratory disease management in PHC facilities with nurses.
Countries
Lost to follow-up
Improvement or
Still sick
Diagnosis change
cure
Thailand
385 98.7%
0
0.0%
5
1.3%
0 0.0%
Kyrgyzstan
5
3.1%
52 39.7%
71 54.2%
0 0.0%
Nepal
222 41.6%
190 35.65
33
6.2%
9 1.7%
Côte d’Ivoire
248 52.8%
57 12.1%
165 35.1%
0 0.0%
Guinea
900 39.2%
1338 58.5%
40
1.7%
0 0.0%
OVERALL
1763 46.2%
1637 42.9%
314
8.2%
9 0.2%
RESPIRATORY CARE IN PRIMARY CARE SERVICES – A SURVEY IN 9 COUNTRIES
0
0
80
0
11
91
0.0%
0.0%
15.0%
0.0%
0.5%
2.4%
Others
390
131
534
470
2289
3814
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Total
108