Chronic obstructive pulmonary disease (COPD) is a progressive lung disease witnessing an increase in its burden worldwide, particularly in low-and-middle-income countries (LMICs). The State Health Resource Centre (SHRC), Chhattisgarh identified a high burden of COPD in the State. The decision makers perceived a lack of evidence-informed interventions to improve quality of care (QoC) among COPD patients at the primary healthcare (PHC) level. The Centre requested our RES team to review the existing evidence on such interventions.

The rapid review we conducted offers an overview of evidence on the interventions to improve QoC for patients with COPD in PHC settings. This would enable decision makers to better manage COPD and improve quality of care among the patients in Chhattisgarh.

Key policy considerations:

1. Smoking cessation is a key measure in improving health outcomes for smokers with COPD. Primary health care centres and professionals should be engaged for providing anti-tobacco initiatives.
2. Patients who smoke should be assisted with smoking-cessation through counselling (behavioural) and pharmacological support to enhance the success of smoking quit rates.
3. Support for smoking cessation for all types of tobacco products including but not limited to cigarettes, cigars, bidi, hookah, chillum etc. should be provided in primary health centres.
4. Primary healthcare professionals may deliver smoking cessation counselling via oral, written instructions or through audio-visual media.
5. Patients should be provided structured education and support on self-management of COPD with written action plans, including signs of worsening symptoms and what to do in that case, medications and doses, and instructions on smoking cessation.
6. Long-acting bronchodilators’ (long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA)) fixed dose combinations (according to local guidelines), in a single inhaler are effective for patients with persisting symptoms and/or exacerbations, as a follow-up treatment to bronchodilator monotherapy. 
7. Future studies including cost analyses are required for definitive conclusions on the health care costs of various strategies in primary health care settings.
8. Trials with a larger sample size, longer follow ups, and tailored interventions should be conducted to address the knowledge gaps relevant to primary health care settings.

The full policy brief and technical supplement document are available below:

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Breast cancer is the most commonly reported cancer among women in India with an incidence rate of 25.8 percent per 100,000 women in 2012. A key strategy of India’s National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) has been to carry out effective primary breast cancer screening among women. The Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis (AIGGPA), an autonomous policy think-tank under the Government of Madhya Pradesh, requested our RES team to review the existing evidence on the usability of palmer ATD-angle measurement to accurately screen women at-risk of breast cancer. The method was perceived as cost-effective, non-invasive and accessible.

The rapid evidence synthesis thus conducted provided AIGGPA with evidence-informed policy options on the use of ATD-angle measurement as an alternative to standard breast cancer screening methods.

Key policy options are:

1. Research done so far on ATD-angle measurement for breast cancer did not use appropriate and rigorous study designs. Further, the studies did not measure the required parameters (sensitivity and specificity) to understand if ATD-angle measurement could be used instead of CBE (alone or in conjunction with USG/mammography) for community screening.
2. Decision-makers may consider prioritising funding for a pilot study to assess the diagnostic accuracy of ATD-angle measurement for breast cancer screening in women using an appropriate study design.

The full policy brief and technical supplement documents are available below:

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The pandemic is putting an unprecedented demand on health systems and the health workforce in India and across countries. Emergency hospital admissions for chronic conditions can further stretch an already strained public health system. There are medications which can affect hospital admissions for patients with such conditions like chronic obstructive pulmonary disease (COPD) and asthma.

This policy brief summarises evidence on such medications from a single high-quality overview of systematic reviews. Recommendations on the medicines based on available evidence are:

1. Long-acting muscarinic antagonists like tiotropium bromide (moderate quality evidence) and long-acting beta 2 agonists like formoterol and salmeterol (moderate quality evidence) can reduce odds of hospital stay of stable COPD patients by 44% and decrease risk of hospital admission by 27% respectively.
2. Inhaled corticosteroids like beclomethasone and short acting antimuscarinic agent such as ipratropium bromide (moderate quality evidence) may be used early in patients with acute asthma exacerbation to reduce the risk of emergency admissions by 58% and 32% respectively.
3. Fluticasone (high quality evidence) increases the risk of pneumonia led hospitalization in patients with moderate to severe stable COPD by 81%

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This report is a part of the Ensuring Health Systems Capacity for COVID-19 and Beyond: Evidence Series. The series aims to provide high quality and contextualised evidence from systematic reviews or rapid evidence synthesis to work on the opportunity the COVID-19 scenario offers i.e., to build a strong, resilient and equitable health system in India and other low-and-middle income countries (LMICs).

The Ministry of Health and Family Welfare (MoHFW), Government of India had released a guidance note which identified the use of telehealth platforms to deliver essential medical services for non-COVID health conditions. The WHO guideline on digital interventions for health system strengthening recognises Mobile Health (mHealth) as an effective means to support such service delivery. It minimises patient-provider contact, thus ensuring physical distancing. mHealth involves the use of mobile devices such as smartphones, patient-monitoring devices, personal digital assistants, and tablets to support public healthcare practices. It could be used effectively by healthcare workers to deliver health services to patients remotely and improve overall communication with co-workers, patients and decision makers. It is important to also outline challenges and enabling factors to adoption of mHealth for delivering healthcare services from health workers’ perspective.

This policy brief summarises evidence on barriers and enablers to the use of mHealth for delivering primary healthcare services by health workers.

Key policy considerations are:

1. Health workers should be encouraged to use mobile devices to initiate remote consultation calls to their patients. To facilitate this, policies and protocols should be in place to explain what can and cannot be done in the remote consultations (i.e.  determine what type of cases warrant face-to-face contact), and to clarify the liability issues of health workers using mobile devices. (high confidence in the evidence).
2. A standardised mHealth training package that covers the generic aspects of use of mobile devices and good data practices should be developed to appropriately train and mentor health workers on the correct use of mobile devices. The package should include the provision of learning and training content via mobile devices to complement traditional methods of delivering continued health education and post-certification training.  
3. Using  mobile devices should lead to reduced travel time to remote/distant places and settings of health workers. Guidelines in collaboration with health workers should be developed to protect them from patients contacting them outside of normal working hours, such as in the context of emergencies or other considerations. (high confidence in the evidence)
4. Health workers need to be aware of the importance of confidentiality of patient information when using mobile devices. mHealth applications for use by health workers to incorporate privacy and confidentiality preserving technologies by design. (high confidence in the evidence).
5. Health workers should use mobile devices to counsel and influence patients' health behaviours in a positive way through health promotion and educational messages. (moderate confidence in the evidence)
6. Health workers need better integration of mHealth interventions with other existing electronic health information systems and to consolidate data dashboard between different vertical programmes. This will improve the usability of their mobile devices and replace the need for physical reporting tools to avoid duplication of data recording and reporting systems. (moderate confidence in the evidence)
7. The use of mobile devices to record routine patient or surveillance data is helpful for decision making. Ensure mechanisms for documenting and tracing past exchanges and decisions made during consultations.

The report provides a summary of evidence from two systematic reviews and a WHO guideline on digital health interventions.

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This report is a part of the Ensuring Health Systems Capacity for COVID-19 and Beyond: Evidence Series. The series aims to provide high quality and contextualised evidence from systematic reviews or rapid evidence synthesis to work on the opportunity the COVID-19 scenario offers i.e., to build a strong, resilient and equitable health system in India and other low-and-middle income countries (LMICs).

Chronic obstructive pulmonary disease (COPD) is preventable and often remains undetected in its mild and moderate forms. The State Health Resource Centre (SHRC), Chhattisgarh identified a high burden of the condition in the State particularly in areas of high industrial pollution. The Centre requested our RES team to review the existing evidence on effectiveness of different case-finding approaches and the accuracy of screening tests for detecting COPD. The evidence was to be relevant to a primary health care setting and from a low-and-middle income (LMIC) perspective.

The rapid review thus conducted provided the SHRC with a summary of evidence-based policy considerations. This would enable decision makers in improving detection of COPD at the primary health care level in Chhattisgarh.

Key policy considerations:

1. Screening for COPD in primary healthcare should be promoted and appropriate training provided.
2. The COPD Diagnostic Questionnaire (CDQ) might be considered as a screening tool for detecting air flow limitation in general population and facilitate early diagnosis. Those with a high score (>16.5 or 17) should undergo confirmatory test.
3. Use of handheld flow meters under the supervision of trained health professionals in addition to COPD questionnaire is likely to improve accuracy in detection of undiagnosed COPD but leads to additional resource investment
4. Provision for pre and post bronchodilator spirometry as a confirmation test for all the suspected cases of COPD in a Primary Healthcare centre is essential

The full policy brief and technical supplement document are available below:

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Asthma is a common chronic respiratory disease with an increasing incidence reported in low-and-middle-income (LMIC) countries. The State Health Resource Centre (SHRC), Chhattisgarh identified a high burden of the condition in the State particularly in areas of high industrial pollution. The Centre requested our RES team to review the existing evidence on interventions to improve quality of care among children and adolescents with asthma. The evidence was to be contextualised for primary health care settings and from an LMIC perspective.

The rapid review thus conducted provided the SHRC with a summary of evidence-based policy considerations. This would enable decision makers in better managing and improving the quality of care among children and adolescents with asthma at the primary health care level in Chhattisgarh.

Key policy considerations:

1. Children and their parents/caregivers should be provided education and support on self-management of asthma including signs of worsening symptoms and what to do in that case. Primary care providers should be provided education on self-management support for asthma patients.
2. Self-management support and education (frequency of inhaler use and proper inhaler technique) should be provided by primary health care staff to improve adherence. Multimedia training (for example, through online video training) should be considered for improving inhaler technique.
3. Medication technique and adherence should be reviewed at each follow-up visit (supported by spirometry results).
4. Peer support might improve quality of life in adolescents. This might be facilitated through the National Adolescent Health Program.
5. Telehealth interventions that are mobile app-based may be considered for consultations and monitoring; however, the additional costs of telemonitoring should be taken into consideration.
6. Prevention of acute exacerbations for asthma is the key to improving quality of care. Considerations for that are covered in a separate policy brief.

The full policy brief and technical supplement document are available below:

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Background & objectives:
The potential benefits of mobile health (mHealth) initiatives to manage the coronavirus disease-2019 (COVID-19) pandemic have been explored. The Government of India, State governments, and healthcare organizations have developed various mobile apps for the containment of COVID-19. This study was aimed to systematically review COVID-19 related mobile apps and highlight gaps to inform the development of future mHealth initiatives.

Methods:
Google Play and the Apple app stores were searched using the terms ‘COVID-19’, ‘coronavirus’, ‘pandemic’, and ‘epidemic’ in the first week of April 2020. A list of COVID-19-specific functions was compiled based on the review of the selected apps, the literature on epidemic surveillance, and national and international media reports. The World Health Organization guideline on Digital Health Interventions was used to classify the app functions under the categories of the general public, health workers, health system managers, and data services.

Results:
The search yielded 346 potential COVID-19 apps, of which 50 met the inclusion criteria. Dissemination of untargeted COVID-19-related information on preventative strategies and monitoring the movements of quarantined individuals was the function of 27 (54%) and 19 (32%) apps, respectively. Eight (16%) apps had a contact tracing and hotspot identification function.

Interpretation & conclusions:
Our study highlights the current emphasis on the development of self-testing, quarantine monitoring, and contact tracing apps. India’s response to COVID-19 can be strengthened by developing comprehensive mHealth solutions for frontline healthcare workers, rapid response teams and public health authorities. Among this unprecedented global health emergency, the Governments must ensure the necessary but least intrusive measures for disease surveillance

Asthma and chronic obstructive pulmonary disease (COPD) are leading causes of mortality and morbidity in India. They have shown an increasing trend in their incidence in the past two decades. The State Health Resource Centre (SHRC), Chhattisgarh identified that there is a high burden of these two health conditions in the State, particularly in areas with high levels of industrial pollution. The Centre requested our RES team to review the existing evidence on prevention of asthma and COPD from a Low-and-Middle Income Countries (LMIC) perspective.

The rapid review thus conducted provided the SHRC with a summary of evidence-based policy considerations to enable decision makers in better managing and preventing asthma and COPD at the primary healthcare level in Chhattisgarh. The key policy considerations presented are:

Primary prevention for Asthma:

1. Parents should be advised to ensure that children are not exposed to environmental tobacco smoke during pregnancy or after birth.
2. Caesarean section increases the risk of childhood asthma. Vaginal delivery should be encouraged, unless medically indicated.
3. Exclusive breastfeeding, where possible is recommended for its overall health benefits.
4. Doctors should advise parents to avoid use of broad-spectrum antibiotics during the first year of a child’s life.
5. Lifestyle modification, including guided weight-loss programmes, exercise and diet should be offered in primary health care centres to obese and overweight children.
6. Dietary restrictions, unguided weight loss or changes during pregnancy should be discouraged for primary prevention of asthma in children.
7. Allergen avoidance as a general strategy for the primary prevention of asthma should be discouraged.

Primary prevention of chronic obstructive pulmonary disease (COPD)

1. Identification and reduction of exposure to risk factors (low birth weight, poor nutrition, acute respiratory infections of early childhood, indoor, outdoor and occupational air pollution) are recommended for primary prevention of COPD.
2. At-risk persons such as pregnant women should avoid exposure to occupational and environmental pollution, including passive tobacco smoke exposure.
3. Community awareness and multi-sectoral co-ordination are required to prevent indoor air pollution (usually from wood and coal for cooking), which is a key risk factor for COPD. Provisions of the Ujjwala Yojana should be used to provide and encourage LPG connections. Additional provisions beyond the free cylinders limit should be considered by the state.
4. Employers should relocate people who are at high-risk for COPD from areas with occupational dust or high air pollution. If this is not possible, employers need to adopt appropriate workplace dust-mitigation measures and/or provide government approved masks that provide adequate respiratory protection.
5. People should be advised on maintaining healthy lifestyle (including healthy diet and nutritional habits), and regular physical activity (for at least for 30 minutes a day).

The full policy brief and technical supplement document are available below:

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Chronic Obstructive Pulmonary Disease (COPD) contributes significantly to health systems burden in terms of primary care consultation, emergency visits and in-patient admissions. The public health systems are under strain due to COVID-19, across the world. Preventing acute exacerbations of COPD is crucial to ensure the health system is not burdened further.

This report summarises how hospital admission for acute exacerbations of COPD might be decreased through institutionalisation of self-management and written action plans for patients. The evidence summary informs governments about modalities for decreasing hospital burden through a patient -centric approach which can be delivered during COVID-19 and beyond

Key policy considerations are:

1. Patients with COPD should be oriented to use self-management strategies with a written action plan for worsening of symptoms. There is evidence that it improves health-related quality of life (high-quality evidence) and reduces hospital admissions due to respiratory problems (moderate-quality evidence).
2. Self‐management and action plans might be delivered by primary healthcare team during follow-up home visits for (as mandated by MoHFW, India guidance note on delivery of essential health services during COVID-19). Primary healthcare teams should be trained for this purpose.  
3. Self-management plans should be individualised with an assessment of COPD and developed based on discussions with patients. Self-management action plans may be delivered in writing (hard copy or digital), verbally or through audio-visual media. Action plans should include guidance and instructions on smoking cessation, self-recognition of COPD exacerbations, and structured education regarding COPD. For safety reasons, action plans should consider co-morbidities and ability to access care rapidly on further exacerbations. 

The document provides a summary of evidence from a single high-quality systematic review which uses reproducible, systematic and robust methods to summarise evidence from multiple research studies (in this case randomised controlled trials) to inform decision making. We summarise effect estimates but also the quality of evidence using the WHO recommended GRADE criteria. 

Download full report (PDF 328 KB)

This report is a part of the “Ensuring Health Systems Capacity for COVID-19 and Beyond: Evidence Series” .
The series aims to provide high quality and contextualised evidence from systematic reviews or rapid evidence synthesis to work on the opportunity the COVID-19 scenario offers i.e., to build a strong, resilient and equitable health system in India and other low and middle income countries.

COVID-19 is an unprecedented pandemic which has led to millions being affected and thousands dying every day across the world.  While the tertiary care systems are being scaled up it is essential to ensure preparedness of Primary Health Centres too. In March 2020, public health physicians from leading institutions, including The George Institute for Global Health, India had formed a collaborative called COVID-19 PHC Action Group.

The COVID-19 PHC action group had earlier developed a preparedness checklist for rural Primary Health Care Centres which has been widely disseminated. The COVID-19 PHC action group based on feedback has now developed a similar preparedness checklist for Urban Primary Health Centres. Dr Tanya Seshadri, MBBS, MD. Coordinator, Tribal Health Resource Centre, Vivekananda Girijana Kalyana Kendra, Karnataka India led the work on this checklist.  Dr Soumyadeep Bhaumik from The George Institute for Global Health has contributed majorly to development of the health systems resource.

The typical reader of this document is a managing a primary care facility (PHC medical officer or manager of an NGO/community health centre) in an urban area. We have kept in mind the typical PHC setting in urban India, noting however that this will vary across states and within it. The document provides a broad checklist for planning and preparedness and will require adaptation to specific setting.