Development, validation, and testing of a physiotherapist initiated checklist of items for implementing pulmonary rehabilitation in Nigeria

INTRODUCTION

Chronic respiratory diseases affect millions of people across all ages, worldwide, and are responsible for substantial morbidity, health-care utilization, socioeconomic loses, and mortality rates.^[1] These diseases are highly prevalent and represent a public health challenge in both industrialized and low-and-middle-income countries (LMICs).^[2,3] Examples of these chronic respiratory diseases include chronic obstructive pulmonary disease (COPD), asthma, pneumoconiosis, interstitial lung diseases, pulmonary sarcoidosis, bronchiectasis, and pulmonary tuberculosis (PTB). At present, nearly 80% of deaths from these diseases occur in LMICs, which accounts for over half of the people with these diseases.^[4] Furthermore, factors such as poor access to optimal health-care services, scarcity of resources, limited expertise for certain interventions (specialized staff), and lack of non-pharmacological interventions such as pulmonary rehabilitation (PR) have been identified to contribute to the high morbidity and mortality from these diseases in LMICs.

PR refers to a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but is not limited to exercise training, education, and behavior change interventions that are designed to improve both physical and psychological outcomes, as well as promoting long-term adherence to health enhancing behaviors in patients with chronic respiratory diseases.^[5] At present, there is substantial and well-documented evidence to support the efficacy of PR for patients with chronic respiratory diseases.^[6-8] Unfortunately, PR services are underprovided in most settings and uptake is mostly poor in those that offer it.^[9]

A few barriers for instituting optimal PR services include lack of trained health professionals to conduct it, patient limited confidence in its effectiveness, and financial load on the patient and health-care system.^[10] Furthermore, PR guidelines for managing chronic respiratory diseases appear to be non-existent for most low-resource settings.^[11] In addition, available treatment guidelines or statements were developed by international stakeholders such as the European Respiratory Society, American Thoracic Society, British Thoracic Society (BTS), and other similar organizations. Unfortunately, these guidelines may not be wholly applicable to low-resource settings because of differences in capacity, health system arrangement, socioeconomic indices, and cultural practices.^[12] There is a need for local guidelines or a checklist (at the least) to improve optimal PR services worldwide. Current efforts from two resource limited settings (Uganda and Congo) have shown that adapting some aspects of PR is efficacious in managing patients with post-PTB, asthma, or COPD.^[13,14] A checklist of items that take into account cultural and health system realities of resource limited settings, and originating from local and relevant respiratory health-care professionals, is necessary. Therefore, this study aimed to develop, validate, and test a physiotherapist initiated checklist of items to aide implementation PR services for Nigerian settings.

MATERIALS AND METHODS

RESULTS

DISCUSSION

This study aimed to develop, validate, and test a physiotherapist initiated checklist of items that can be utilized as a guide for implementing PR in the Nigerian health-care settings. The study offers one of the first attempts aimed at providing a guiding template for implementing PR in a low-resource African setting. In addition to helping to institute specialized care such as PR, this checklist of items can help authorities to quantify the minimal standard for practice required when instituting PR services, which is not only scarce, but non-existent in most low-resource settings.^[15]

Even though there are a few studies that have utilized an adapted form of PR in the African settings, there has been no mention of a guideline or any evidence-based recommendations covering all aspects of PR.^[4] Therefore, this checklist of items may offer an important initial step toward achieving a more standardized and uniform PR services in Nigeria and similar settings.

This guideline checklist primarily emanated from cardiopulmonary physiotherapists practicing in Nigeria. This is because physiotherapists play a major role during rehabilitation of patients. For example, patients with COPD are known to greatly benefit from PR, especially those that require more exercise training, which is a cornerstone of PR.^[16,17] Furthermore, PR is mainly offered in local settings through a direct referral from a physician to a physiotherapist. Consequently, there is a high likelihood that physiotherapists (respiratory) will likely be more conversant, interested, and possibly have a better knowledge of PR. Furthermore, other health-care professionals, aside doctors and physiotherapists, that form part of the PR team often lack adequate knowledge of PR services because these services are either limited or non-existent. Specifically, the role played by physiotherapists managing patients with chronic respiratory disease in our setting is usually delayed until after pharmacotherapy has been initiated. Moreover, these roles mainly aim to improve ventilation through the use of breathing exercises, inspiratory muscle training, aerobic exercises, and other adjuncts.^[18] Physiotherapists have also been reported to have advanced knowledge and skills in PR.^[19]

Existing international statements or guidelines often vary because they take into account environmental and health-care settings peculiarities when offering a guideline.^[20-23] Our results confirm the presence of these variations because not all the items on our checklist were fully addressed by the BTS guideline in the pilot test. At present, since there is a lack of recommendation or guidelines that originate from LMICs/African settings, there is a need for a full guideline to be commissioned by a relevant professional association. Moreover, as it stands, it has been recommended that existing guidelines should only be used after local adaption have been done.

At present, developing a “full guideline” is expected to follow the rigor as stated in the AGREE II recommendations which may include using systematic reviews/meta-analyses and Delphi procedures. However, since the evidence profile to support the use of PR in LMICs is limited, we had to use a panel generated list of items in our study. Moreover, since optimal PR services are not currently provided by a team of respiratory health professionals in Nigeria in a specified department, using a Delphi design may not be feasible to address our study objectives.

Due to the need to enhance the acceptability of this checklist of items, we included a face validation component, whereby chest physicians and other allied respiratory professionals were invited to rate each item included in the initial checklist draft. This has helped our checklist to be potentially acceptable among important stakeholders that make up the PR team, and possibly reduce any potential bias. PR is typically offered by a team mainly comprising physicians, physiotherapists, occupational therapists, nurses, social workers, psychologists, and nutritionists/dieticians.^[24] At present, most of these professionals in Nigeria are not involved directly in rehabilitation due to several reasons such as lack of awareness, expertise, and skill.^[25] This may explain why the validation was not completed by some of the respiratory health professionals.

The BTS guideline is of high quality that was developed in accordance with the AGREE recommendations.^[26] Nevertheless, the BTS guideline did not address some of the items included in our checklist. For example, music has been used as an adjunct during PR of post-TB adults in Uganda (Jones et al., 2017) and may be relevant for the Nigerian population. There is also evidence to support the use of items like TENS for managing pain and certain muscle weaknesses among some patients with chronic respiratory disease undergoing rehabilitation.^[27,28] Similarly, incentive spirometry one of the important physiotherapy gadgets is indicated for some chronic respiratory disease patients (especially post-surgery or prone to atelectasis).^[29] Moreover, Nigerian physiotherapists often use it routinely during management of these patients.

Therefore, in the next steps, there is a need to compare this checklist with other international guidelines or perform additional studies in the Nigerian settiong. There is also a need to ascertain the evidence profile from high-quality systematic reviews and meta-analyses of African studies that focus on the appropriateness of efficacy of the items included in this checklist in the future.

Finally, it is our expectation that resource-limited settings in Nigeria and other settings with similar cultural and health systems to take consider or possibly adapt the items presented in this checklist before instituting PR services. Perhaps the number of patients with chronic respiratory diseases that lack access to optimal PR^[30] could benefit pending the commissioning a full guideline.

CONCLUSION

A checklist of items for the implementation of pulmonary rehabilitation in Nigeria was successfully developed, validated and tested. This checklist could be utilized as a resource for delivering pulmonary rehabilitation services in Nigeria and other similar settings. Nevertheless, we recommend the need for a full guideline in view of the potential disparities with existing international guidelines.