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Lung health across the life course in Malawi

Rylance, Sarah (2020) Lung health across the life course in Malawi, Thesis (Doctoral), Liverpool School of Tropical Medicine.

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S Rylance - Lung health across the life course in Malawi_PhD thesis and appendices (Final).pdf - Accepted Version

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Background: Chronic respiratory symptoms are common in Malawian adults and might be determined by lung development, growth and exposures in earlier life: alternative cooking methods, such as cleaner-burning cookstoves, have been proposed as a way to reduce biomassfuel smoke exposure and improve lung health. Tailored strategies for resource-limited settings are needed to improve the management of common childhood respiratory conditions.

Aims: 1. To explore the prevalence of non-communicable lung disease and air pollution associated determinants in children and adults in rural Malawi 2. Evaluate a novel task shifting approach to asthma management for children.

Methods: Within the same rural Chikhwawa communities, we conducted a prospective cohort study of adults, collecting respiratory questionnaire data, spirometry and personal air pollution exposure measurements at three timepoints over 3-years, and a cross-sectional study, collecting similar data from children aged 6-8 years at one timepoint. We also conducted a randomised-controlled trial and qualitative sub-study to evaluate the feasibility and effectiveness of a task shifting intervention, using non-medically trained asthma educators, on asthma outcomes. The intervention comprised detailed clinical assessment, optimisation of inhaled treatment, and asthma education delivered by lay educators. Asthma symptoms and exacerbations, spirometry and exhaled nitric oxide were assessed at 3-months.

Results: We recruited 1481 adults, mean (SD) age 43.8 (17.8) years, (654 with acceptable spirometry at ≥2 timepoints) and 804 children, mean (SD) age 7.1 (0.8) years, (522 with acceptable spirometry) in Chikhwawa. Forced expiratory volume in 1 second (FEV1) and Forced
Vital Capacity (FVC) decline were 30.9 ml/year (95% confidence interval (CI): 21.6-40.1) and 38.3ml/year (95% CI: 28.5-48.1), respectively: comparable to natural age-related decline seen in healthy non-smokers in high-income settings. Lung function z-scores, referencing Global Lung Initiative African-American predicted values, were similar in children and adults and we found no evidence of an association between personal air pollution exposure and lung function or respiratory symptoms. Secondary analysis of a sub-group of children from households previously enrolled in a cookstove trial suggested a potential benefit: children from intervention households had a lower carboxyhaemoglobin level and higher FVC z-scores compared to controls.
We recruited 120 asthmatic children at a tertiary hospital in urban Blantyre; 59 received the intervention, 61 continued with standard care in the outpatient clinic. At 3-months, we found a clinically and statistically significant improvement in the primary outcome: asthma control in intervention vs standard care group (increase in mean (SD) cACT score of 2.7 (2.8) vs 0.6 (2.8), p<0.001). In addition, fewer children receiving the intervention required emergency health care (7.3% vs 23.7%, p=0.03) or missed school (20.0% vs 61.0%, p<0.001) due to exacerbations. Children and carers described the positive impact of asthma education on their knowledge levels and increased confidence to self-manage symptoms.

Implications: Our findings from Chikhwawa suggest that lung function deficits seen in adults are present in childhood, and that early life influences are likely an important contributor to adult lung health. Future research should consider public health interventions addressing multiple adverse risk factors encountered in utero and early childhood.
Task shifting asthma education roles resulted in improved asthma outcomes and high levels of patient satisfaction, suggesting this could be an effective strategy in resource-limited settings.
Further research is needed to assess the wider application of this approach across all levels of health facility.

Item Type: Thesis (Doctoral)
Subjects: WA Public Health > Health Problems of Special Population Groups > WA 395 Health in developing countries
WA Public Health > Air pollution > WA 754 Pollution and pollutants (incl. tobacco pollution; passive smoking)
WF Respiratory System > WF 140 Diseases of the respiratory system (General)
WF Respiratory System > WF 20 Research (General)
WF Respiratory System > Lungs > WF 600 Lungs
Repository link:
Item titleItem URI
Non-communicable respiratory disease and air pollution exposure in Malawi: a prospective cohort study
Lung health and exposure to air pollution in Malawian children (CAPS): a cross-sectional study
Faculty: Department: Clinical Sciences & International Health > Clinical Sciences Department
Depositing User: Lynn Roberts-Maloney
Date Deposited: 30 Sep 2020 11:32
Last Modified: 30 Dec 2020 02:02


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