1

INTRODUCTION

Lung disease is a high morbidity and mortality disease worldwide.
Common lung diseases (CLDs) are acute pneumonia, tuberculosis (TB),
bronchial asthma, chronic obstructive pulmonary disease (COPD), lung
cancer... Some common chronic lung diseases such as TB, bronchial asthma,
COPD are the main cause of death in adults. At present, TBremains a major
health problemworldwide. COPD isthe third leading cause of death. The
number of asthma infected and death tend to increase. In Thai Nguyen, the
prevention and control of CLDs is still limited, especially at the grassroots
healthcare level. Each year, TBincidence rate ranges from 45% -50% of the
estimated infection sources in the community. Patients with bronchial
asthma andCOPD have not been timely diagnosed and most of them have
not been properly treated managed, the leading cause is the weak capacity of
commune health workers (CHWs).
The study,“The situation of detecting and managing some common lung
diseases at commune health stations in Thai Nguyen province and
effectiveness of some intervention solutions”aims to achieve following
objectives:
1. To describethe situation of detecting and managing some common
lung diseases of commune health workersin Thai Nguyen province in 2013.
2. To analysis some factors related todetect andmanagesome common
lung diseases of commune health workersin Thai Nguyen province.
3. To evaluate the effectiveness some solutions in improving the
detection and management of some common lung diseases of commune
health workersin Thai Nguyen province after 2 years of intervention.


2



3

had not yet participated in the prevention of lung diseases; the province and
district surveillance was not good.
3. Effectiveness of some solutions in improving the detection and
management of some common lung diseases of CHWs in Thai Nguyen
province after 2 years of intervention
- The enhanced training solutionto improve knowledge, attitudes and
skills for CHWs on the management of CLDs in the intervention commune
was very good. Intervention effect on good knowledge was 223.8%, good
attitude was 85.4% and good skills was 292.6%.
- The enhanced communication solution for people with intervention
effect on good knowledge 169.0%, good attitude 17.2% and good skills
94.5%.
- The “Department of Chronic Lung Disease Management” model had
rapidly increased results of the number of managed people with bronchial
asthma, COPD, annually.
- The "Green breathing club" model at the province level and 15 clubs
at the commune level were operated regularly, achieved positive effects for
patients and community, had highly appreciated by patients.
- The results of the CHWs had properly managedCLDs in two
intervention districts was much higher than the two control districts.
STRUCTURE OF DISSERTATION
The dissertation has 134 pages, excluding the appendix:
Introduction: 2 pages
Chapter 1. Literature review: 30 pages
Chapter 2. Subjects and methods: 30 pages
Chapter 3. Study results: 37 pages

TBdetection. The PAL experiments in many countries around the world
have been proven the high effectiveness.
1.1.2. In Viet Nam
At CHS, more than 30% of people have health examination for
symptoms such as coughing or difficult breathing. These symptoms are
manifestations of respiratory diseases, including TB, bronchial asthma, and
COPD. The majority of those patients were not got sputum tests to detect
TB by CHWs, but are often diagnosed with other lung diseases and most of
them are prescribed antibiotics. Thus, TB is usually overlooked; bronchial
asthma and COPD are diagnosed late and not properly treated.
1.2. Some related factors to the detection and management of CLDs
1.2.1. Direct factors
1.2.1.1. Human resources and professional qualifications
In human resources, besides the illogicality of number and structure,
CHWs are rarely trained and retrained. Therefore, knowledge gradually
erodes. There is rarely in training for new knowledge of detecting and
managing CLDs (bronchial asthma, and COPD), greatly affecting the


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professional quality at CHS. This is a not goodrelated factor to general
medical examination and detection, management of CLDs.
1.2.1.2. Counseling skill on prevention and control of some CLDs
CHWs are weak in counseling skills for many diseases, including
CLDs. Therefore, it is necessary to improve the capacity of CHWs in terms
of CLDs counseling skills. This is also a not good related factor to general
medical examination and treatment, detection and management and
detection, management of CLDs.
1.2.2. Indirect factor

1.3.2. The applicable solutions in Vietnam
- Continuing to well implement the DOTS strategy: From 1996,
Vietnam began to implement the DOTS strategy. Until 1998, DOTS strategy
had been implemented nationwide and maintained to achieve good results.
Therefore, it is necessary to continue in well-implementing the DOTS
strategy in the future.
- Implementing the PAL strategy: Data from countries show that PAL is
very effective in preventing lung diseases. PAL raises the awareness of the
community about the symptoms of respiratory diseases, increases the
professional qualification of the CHWs, reduce referrals to avoid
overcrowding, reduce the treatment cost due to earlystandard detection and
management. Especially,

PAL significantly increases the rate of

TBdetection. Therefore, in the upcoming time, Vietnam needs to consider
and evaluate the PAL pilot results for nationwide deployment.

Chapter 2. SUBJECTS AND METHODS
2.1. Study subjects
CHWs, the TBcontrolprogram staffs at district health center andprovince
level, village health workers, primary health care committee staffs, village


7

leaders; commune women staff, CLDs patients, CLD reports in the
commune.
CHWs are directly received, examine and manage for people with CLDs.
Village health workers support CHWs in CLDs prevention. People and CLD

staffs and village leaders,
+ A guideline for group discussion of commune women staffs and
village health workers,
+ A guideline for group discussion of lung and TB patients;
+ Secondary data collection form.
+ Training material on practical management skills about CLDs,
+ Training material on communication and health education skill about
CLDs.
2.3. Methodology
2.3.1. Methodology and study design
The descriptive and intervention study methods was conducted,
combined both quantitative and qualitative study.
- Using 2 study design:
+ Cross-sectional descriptive
+ Community interventionwith controlled before-and-after study
- The study was divided into 2 stages:
+ Stage 1:
FromMay 2013 toJune 30th2013, a cross-sectional descriptive study was
conducted to survey the CLDsdetection and management of CHWs in
communes in all province and describe factors related to CLDs management
capacity of CHWs.
+ Stage 2:
From July 1st2013 toJune 30th2015,community intervention with
controlled

before-and-after

study

was

- KAP study sample technique in people:
Sample size: Apply a formula to calculate population with specified
absolute precision:
n = Z2(1 - α/2)

 p(1 

Of that:

d

p )

2

+ n is the minimum sample size;
+ Z(1 - α/2)with 95%confidencelevel, Z(1 - α/2) = 1.96;
+ pis the proportion of people with a good understanding of TB,
according to the Nguyen Quoc Hoan study results0,5;
+ d iserrors between sample and population, d = 0.05.


10

According the formula:n = 385.
To prevent errors due to study subjects giving up during the study,
increase the sample size by 5% and round up to 400 people.
Sampling technique:
Randomly select 4 communes of 4 study districts (each district selected 1
commune). Randomly select 100 adults / 1 commune.

- Each district has 1 group discussion between district TBcontrol
program secretary, district center for disease control staff, CHS leaders,
CHWs in charge of TB control program.
- Each district randomly select 1 commune for group discussion.
* Interventionsolutions
- At communes of 2 intervention districts, conducted 03 activities:
Activity 1:
+ Improvingthe capacity of CHWs on the CLDs management practice.
+ Improving the capacity of CHWs and village health workersin health
education and communication to prevent CLDs.
Activity 2:
+ Improve TB knowledge for people and community.
+ Support communication materials about lung disease and TB for CHS.
+ Enhanced the inspection and surveillance activities of the preventing
and controllingTB and lung diseases at the province and district level to
communes.
+ Organizethe monthly meeting between province, district and commune
level on the practice of CLDs management and TB detection(integration).
Activity 3:
Building up "Green breathing club": develop 15 clubs in communes of
two intervention districts. Participants of the club are patients, patients'
relatives, CHWs and volunteers.
- At Thai Nguyen Tuberculosis and Lung hospital:
+ Building one room for chronic lung disease management (CMU).
+ Building a "Green breathing club".
- Group discussion in districts before and after the intervention:
+ Group discussion with district health centerstaffs, CHS leaders (15
people)



P1
Of that: p1 is the rate before and p2 is the rate after intervention.
+ Efficiency index

(EI) % =

+ Intervention effect(IE) = EIintervention- EIcontrol


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* Survey secondary data on the detection and management of CLDs at all
CHSof the studied districts.
* Data analysis methods
- Quantitative data were analyzed on SPSS 20.0 software.
- Qualitative data: analysed the audio and video tapes, records...
2.4. Ethical approval
This is a pilot study in the community to find appropriate solutionin
improving the capacity of CHWs to detect and manage some CLDs at CHS.
In the study process, it did not have adversely affect the environment,
health and got community acceptance.
The study was conducted after get ethic approval from the ethic council
of Thai Nguyen University of Medicine and Pharmacy.

Chapter 3. STUDY RESULTS
3.1. The situation of detecting and managing some common lung
diseases of CHWs in Thai Nguyen province in 2013
3.1.2. The situation of skills of asking, examining and managing CLDs of
CHWs in Thai Nguyen province in 2013
3.1.2.1. Quantitative results

38.7
15.6
17.0


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The rate of CHWs were qualifiedmanagedafter asking questions and
examining was very low, especially only 15.6% had clear and complete
medical records; 17.0% guidedpatients to take sputum for TB testing.
3.1.2.2. Qualitative results
Box 3.1. Assessment of district and CHS staffsabout the situation
of detecting and managing CLDs of CHWs
Mr. N.V.T - Van Han CHS, Dong Hy:
“...The situation of lung diseases in Van Han commune as well as
the other communes of Dong Hy district is still very severity. Each year,
the number of patients with lung disease symptoms visit CHS accounted
for 25% –30%…”.
Mr. H.S.H– Dong Hy district health center:
“... The qualifications of CHWs are not high and equal, the
examination and management of lung diseases are not good, not
regularly guide people with pulmonary symptoms to get sputum for TB
testing; skills for examination and management of general lung diseases
are limited...”.
Mr T.V.T –Thanh Cong CHS:
“...CHWs’ qualifications basically meet the standard requirements of
common medical examination and management at the commune level,
however, with chronic lung diseases and TB, which are specialized
diseases, the CHWs' capacity is still limited in examination skills,
diagnosis, management...”.

82

29.1

Not good attitude

200

70.9

Good skill

92

32.6

Not good skill

190

67.4

KAS

The number of CHWs with good knowledge about the management of
CLDs was only 21.6%, good attitude 29.1%, good skills only 32.6%.

Rate%

Good

and management
Mr. N.V.V- Pho Yen district health center:
“In general, the knowledge about CLDs of CHWs is limited, due to
low and unequal qualifications of CHWs. The CLDs such as bronchial
asthma, COPD have less training, so they do not know clearly, lead to
confused diagnosis, not good management…”.
Mr. D.V.T- Linh Son CHS
“The CHWs attitude about CLDs management is still not good
because they are unaware of the CLDs danger level, leading to subjectivity.
In addition, bronchial asthma and COPD require equipmentfordiagnosis
support testing but there is no equipment at the commune level, so most case
was managed by experience...”.
The direct related factors to the capacity of CHWsin detecting and
managing CLDs were KAS about CLDs.
3.2.2. Group of indirect influencing factors
Table 3.8. KAP for prevention and control CLDs of people (n=400)
People

No

Rate %

Good knowledge

111

27.8

Not good knowledge



17

The rate of good knowledge about prevention and control CLDs was
very low (27.8%); good attitude, 34,5%; good practice (25.3%).
Table 3.9. Other indirect related factors
Evaluation of CHWs

Level

Factor

Good

%

Not good

%

CHS facilities

104

36.9

178

63.1


Have enough CHWs as standard

162

57.4

120

42.6

258

91.5

24

8.5

226

80.1

56

19.9

119

42.2


Average numbers of comments

164

58.2

118

41.8

Vilage health workers supports CHWsin
TB detection
CHS develop plans to detectTB
CHS develop plans to detectchronic lung
diseases
The involvement of party committee,
commune committee
Commune organizations are involved in
the prevention of CLDs

There was 41.8% CHWs assessed the not good level indirect related
factors of CLDs prevention in the commune.
3.3. Effectiveness some solutions in improving the detection and
management of some CLDs of CHWs in Thai Nguyen province after 2
years of intervention
3.3.1. Developed solutions:


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Rate %

60
50
40
30
20

Good knowledg

Good attitude
28.2

24.4 34.6

37.2
23.1

Not good attitude
20.5

10

Good skill
Not good skill

0
Intervention team



Good knowledge
Not good knowledge
Good attitude

60

Not good attitude

40

20.5
30.8

20
3.9

33.3

2.6

28.2

Good skill
Not good skill

0

Intervention team



Good attitude

88.9

3.5

85.4

Good skill

333.8

41.2

292.6

The IE for CHWs were very good: good knowledge was 223.8%, good
attitude was 85.4% and good skill was 292.6%.


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3.3.2.2. Solution 2 effectiveness: strengthening communication activities in
preventing and controlling some CLDs in the community.
Table 3.24. KAP changes of people on prevention and control of CLDs
EI (%)

Effectiveness



25.5

94.5

for KAP

IE on prevention of CLDs of the people wit good knowledge 169%, good
attitude 17.2%, good practice 94.5%.
3.3.2.3. Solution 3 effectiveness: chronic lung disease management unit
Table 3.26. The number of asthma, COPD patients who register
and manage at CMU accumulate annually (up to 31/12/2016)
Year

Asthma

COPD

Total

2015

0

354

354

2016
Gain

N

Member

After two years of intervention, a "Green Breathing" club has been
developed in the provincial TB and lung hospital and 15 "Green Breathing"
clubs in the communes of the two intervention districts. Of that, Pho Yen had
9 clubs, Dong Hy had 6 clubs, each club had an average of 30-40 members.
The total number of members in the province was 998 with 563 at provincial
TB and lung hospital and 435 at commune clubs.
3.3.2.5. Overall effectiveness of solutions: patients with common lung
disease in 2 intervention districts are properly treated
Table 3.29. The testing resultsfor TB detection
At two districts before and after intervention
Index
Year

Total

Sputum test
Dong
Pho Yen
Hy

Total

AFB(+)
Dong
Pho
Hy

Gain

871

439

432

23

14

9

108.4%

116.8%

28.7%

29.2%

28.1%

112.4%

The intervention results showed significantly increased the number of
suspected people forTBsputum testing (an increased of 108.4% in Dong Hy
and 116.8% in Pho Yen; and overall 112.4%). The number of patients with



45

55

42

16

26

2015

402

234

168

234

106

128

Gain

302

123

Year

Sputum test
Total

AFB(+)

Phu

Phu

Binh

Luong

Total

Phu

Phu

Binh

Luong

2013

706

331


-2

-1

-0.14%

-13.8%

34.7%

-4.62%

(-5.1%

-3.9%

Gain

The results of TB detection test in 2 control districts after 2 years (no
intervention, monitoring at the same period time with intervention districts)


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were equivalent in both the number of suspected TB patients for sputum
testing and the number of pulmonary TB AFB (+).
Table 3.34. The results of asthma, COPD detection at two control
districts after 2 years of monitoring without intervention
Diseases

29

27

62

35

27

2015

68

35

33

66

34

32

Gain

12

6



(%)

No

Rate
(%)

Gain
No

Rate

p

(%)

COPD

42

15.2

234

84.8

192

457.1


COPD

62

48.4

66

51.6

4

6.45

>0.05

test

interven
tion

Sputum

control

Rate

2015

775

state of patients 52.5%; describe skin, lips, mucous membrane47.2%, take
temperature 40.8%, breath rate counting 27.7%; inspection 70.9%; palpation
25.9%; percussion 23.8%; only auscultation was 89.0%.
- The percentage of CHWs achieved standard requirements for disease
management was very low: announce the disease for patients 52.8%; patient
instruction for continuous activities 51.8%; encouraged patients38.7%; write
clearly recorded medical records15.6%, especially only 17.0% had
instructed patients to have sputum for TB detection.
2. Some related factors for detection and management of CLDs of
CHWs
The detection and management about CLDs of CHWs were not good
because:


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- KAS about detection and management on CLDs of CHWs was not
good, only 21.6% had good knowledge, 29.1% had good attitude, 32.6% had
good skills; counseling skills of CHWswere not good: good was 54.3%,
moderate was 18.0% and weak was 27.7%. CHWs had many tasks: 57.8%
had 3 or more tasks, 29.8% had two tasks.
- KAP ofpeople'son prevention and control lung disease were not good:
only 27.8% had good knowledge, 34.5% had good attitude and 25.3% had
good practices.
- Some other indirect related factors were: Facilitiesare not good; lack of
medical equipment; lack of CHWs...
3. Effectiveness of some solutions in improving the detection and
management of some CLDs of CHWs after 2 years of intervention
- The enhanced training solution for CHWsachieved IE on good
knowledge 223.8%; good attitude 85.4%; good skills 292.6%.