Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare Professionals

International Journal of Chronic Obstructive Pulmonary Disease Dovepress open access to scientific and medical research International Journal of Chronic Obstructive Pulmonary Disease downloaded from https://www.dovepress.com/ on 23-Feb-2022 For personal use only. Open Access Full Text Article ORIGINAL RESEARCH Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare Professionals Fanuel Meckson Bickton Harriet Shannon1 1,2 1 UCL Great Ormond Street Institute of Child Health, London, UK; 2Lung Health Research Group, Malawi-LiverpoolWellcome Trust Clinical Research Programme, Blantyre, Malawi Correspondence: Fanuel Meckson Bickton Lung Health Research Group, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, P.O. Box 30096, Chichiri, Blantyre 3, Malawi Tel +265 982 55 23 53 Email Introduction: Low- and middle-income countries bear a disproportionately high burden of global morbidity and mortality caused by chronic respiratory diseases. Pulmonary rehabilita tion is recommended as a core intervention in the management of people with chronic respiratory diseases. However, the intervention remains poorly accessed/utilised globally, especially in low- and middle-income countries. Aim: This qualitative study explored barriers and enablers to pulmonary rehabilitation in low- and middle-income countries from the perspective of healthcare professionals with pulmonary rehabilitation experience in these settings. Methods: Online-based semi-structured in-depth interviews with healthcare professionals were undertaken to data saturation, exploring lived barriers and enablers to pulmonary rehabilitation in their low- or middle-income country. Anonymised interviews were audiorecorded, transcribed verbatim, and analysed using thematic analysis. Results: A total of seven healthcare professionals from seven low- and middle-income countries representing Africa, Asia, and South America were interviewed. They included five physiotherapists (four females), one family physician (male), and one pulmonologist (female). Themes for barriers to pulmonary rehabilitation included limited resources, low awareness, coronavirus disease 2019, and patient access-related costs. Themes for enablers included local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Conclusion: Barriers to pulmonary rehabilitation in low- and middle-income countries include limited resources, low awareness, coronavirus disease 2019, and patient accessrelated costs. Enablers include local adaptation, motivated patients, coronavirus disease 2019 (which spanned both enablers and barriers), better awareness/recognition, provision of PR training, and resource support. Successful implementation of these enablers will require engagement with multiple stakeholders. The findings of this study are a necessary step towards developing strategies that can overcome the existing pulmonary rehabilitation evidence-practice gap in low- and middle-income countries and alleviating the burden of chronic respiratory diseases in these countries. Keywords: chronic respiratory diseases, pulmonary rehabilitation, low-income countries, middle-income countries, barriers, enablers Introduction Pulmonary rehabilitation (PR) is a core component in the management of people with chronic respiratory diseases (CRDs). It is defined as International Journal of Chronic Obstructive Pulmonary Disease 2022:17 141–153 Received: 10 November 2021 Accepted: 24 December 2021 Published: 13 January 2022 141 © 2022 Bickton and Shannon. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress. com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Dovepress Bickton and Shannon a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies, which include, but are not limited to, exercise training, education, and behaviour change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adher ence of health-enhancing behaviours.1 experiences in implementing or delivering PR in an LMIC setting.22 One-to-one semi-structured interviews with participants elicited individual participant insights into their experiences regarding barriers and enablers to PR in their respective LMIC.23,24 PR leads to significant reductions in symptoms such as dyspnoea, fatigue, anxiety and depression, and significant improvements in exercise tolerance and overall healthrelated quality of life.2 Data from high-income countries suggest that it also significantly reduces the direct costs of chronic obstructive pulmonary disease (COPD) by decreasing unnecessary use of the healthcare system, par ticularly unplanned hospital admissions.3 While the bulk of this evidence is based on those with COPD,2 there is also evidence supporting effectiveness of PR in people with other CRDs including asthma,4 post-tuberculosis lung disease5 and bronchiectasis.6 In addition, PR is costeffective as it may be delivered using minimal, low-cost equipment, making its implementation feasible even in low- and middle-income countries (LMICs) where access to specialist exercise equipment may be limited.7,8 Although PR is recommended in various national and international guidelines for the management of people with CRDs, notably COPD and bronchiectasis,3,9 it remains poorly accessed or underutilised around the world.3,10,11 Specifically, referral and patient uptake is poor.12 In addition, although it is LMICs that are disproportionately burdened by CRDs,13 current PR evidence is mainly based on studies from high income countries.14 Of the eight papers exploring barriers and enablers to PR, none were from LMICs.10,12,15– 20 LMICs have different challenges to high income countries in terms of access to resources, meaning that current litera ture cannot be generalised. Moreover, it has been reported that clinical PR services are not widely available in LMICs21 due to certain barriers. This study aimed to explore those barriers (and enablers) to PR in LMICs from the perspective of health professionals with PR work experience in these countries. This would be a necessary step towards develop ing strategies that can overcome the existing PR evidencepractice gap.10 Participants were purposively r (...truncated)