The Development and Characteristics of Planetary Health in Medical Education: A Scoping Review.

PURPOSE: Climate change, biodiversity loss, and other ecological crises threaten human health globally. The interrelation between human health and ecosystems is addressed in the emerging field of planetary health. Ecological crises have created an urgency to integrate planetary health, including sustainable health care, into medical education. To facilitate integration and guide future research, this review aims to provide an overview of the existing literature about planetary health in medical education. METHOD: The authors conducted a scoping review using the conventional methodological framework for scoping studies. They performed a comprehensive search in 7 databases without language restrictions in March 2022. Two researchers independently extracted data. The team analyzed the data using data-driven thematic analysis, content analysis, and qualitative summarizing. Data were structured according to the Curriculum Development for Medical Education: A Six-Step Approach. RESULTS: The authors identified 3,703 unique publications, of which 127 were included. Articles predominantly (71%, n = 90) covered the call to integrate planetary health in medical education (step 1: general needs assessment). Many publications (24%, n = 31) proposed learning objectives (step 3); these mainly concerned raising awareness while few concerned action perspectives. Publications limitedly reported on the final steps of curriculum development. Only 2 covered a full cycle of curriculum development. Most were published recently, with first authors mainly from Europe and North America. CONCLUSIONS: Planetary health in medical education is an urgent and hot topic. Literature focused predominantly on why planetary health should be integrated in medical education and what should be covered. The authors recommend future research and education development to shift to how to do so, especially in evaluation and feedback. Research and education development needs to be conducted and reported on systematically and underpinned by educational principles. Lastly, it would benefit from perspectives beyond 'Western-based' ones.

SERIES: eHealth in primary care. Part 6: Global perspectives: Learning from eHealth for low-resource primary care settings and across high-, middle- and low-income countries.

BACKGROUND: eHealth offers opportunities to improve health and healthcare systems and overcome primary care challenges in low-resource settings (LRS). LRS has been typically associated with low- and middle-income countries (LMIC), but they can be found in high-income countries (HIC) when human, physical or financial resources are constrained. Adopting a concept of LRS that applies to LMIC and HIC can facilitate knowledge interchange between eHealth initiatives while improving healthcare provision for socioeconomically disadvantaged groups across the globe. OBJECTIVES: To outline the contributions and challenges of eHealth in low-resource primary care settings. STRATEGY: We adopt a socio-ecological understanding of LRS, making LRS relevant to LMIC and HIC. To assess the potential of eHealth in primary care settings, we discuss four case studies according to the WHO 'building blocks for strengthening healthcare systems'. RESULTS AND DISCUSSION: The case studies illustrate eHealth's potential to improve the provision of healthcare by i) improving the delivery of healthcare (using AI-generated chats); ii) supporting the workforce (using telemedicine platforms); iii) strengthening the healthcare information system (through patient-centred healthcare information systems), and iv) improving system-related elements of healthcare (through a mobile health financing platform). Nevertheless, we found that development and implementation are hindered by user-related, technical, financial, regulatory and evaluation challenges. We formulated six recommendations to help anticipate or overcome these challenges: 1) evaluate eHealth's appropriateness, 2) know the end users, 3) establish evaluation methods, 4) prioritise the human component, 5) profit from collaborations, ensure sustainable financing and local ownership, 6) and contextualise and evaluate the implementation strategies.

[Planetary Health in medical education: rapidly catching up]. / Planetary health in medisch onderwijs.

Healthcare professionals have a responsibility to protect and promote human health, and thus also have a responsibility to protect ecosystems and to promote Planetary Health. Planetary Health arose recently in medical education and is growing exponentially. Planetary Health in medical education should entail three key themes: (a) Understanding of the complex relationship between humankind and nature - the core of Planetary Health. With related knowledge, students can develop the skills and attitude to: (b) act from their healthcare perspective; apply adaptation and mitigation measures; and (c) reflect on and act according to their role within society. Preconditions for successful implementation of Planetary Health in medical education are a broad support among stakeholders, formal ratification (in learning outcomes, assessments, accreditation), capacity building among educational institutes, resources for education development (finance, time), and transdisciplinary collaboration; From students to education headmasters, everyone has a role to fulfil in integrating Planetary Health into medical education.

eHealth-Based Psychosocial Interventions for Adults With Insomnia: Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Worldwide, insomnia remains a highly prevalent public health problem. eHealth presents a novel opportunity to deliver effective, accessible, and affordable insomnia treatments on a population-wide scale. However, there is no quantitative integration of evidence regarding the effectiveness of eHealth-based psychosocial interventions on insomnia. OBJECTIVE: We aimed to evaluate the effectiveness of eHealth-based psychosocial interventions for insomnia and investigate the influence of specific study characteristics and intervention features on these effects. METHODS: We searched PubMed, Embase, Web of Science, PsycINFO, and the Cochrane Central Register of Controlled Trials from database inception to February 16, 2021, for publications investigating eHealth-based psychosocial interventions targeting insomnia and updated the search of PubMed to December 6, 2021. We also screened gray literature for unpublished data. Eligible studies were randomized controlled trials of eHealth-based psychosocial interventions targeting adults with insomnia. Random-effects meta-analysis models were used to assess primary and secondary outcomes. Primary outcomes were insomnia severity and sleep quality. Meta-analyses were performed by pooling the effects of eHealth-based psychosocial interventions on insomnia compared with inactive and in-person conditions. We performed subgroup analyses and metaregressions to explore specific factors that affected the effectiveness. Secondary outcomes included sleep diary parameters and mental health-related outcomes. RESULTS: Of the 19,980 identified records, 37 randomized controlled trials (13,227 participants) were included. eHealth-based psychosocial interventions significantly reduced insomnia severity (Hedges g=-1.01, 95% CI -1.12 to -0.89; P<.001) and improved sleep quality (Hedges g=-0.58, 95% CI -0.75 to -0.41; P<.001) compared with inactive control conditions, with no evidence of publication bias. We found no significant difference compared with in-person treatment in alleviating insomnia severity (Hedges g=0.41, 95% CI -0.02 to 0.85; P=.06) and a significant advantage for in-person treatment in enhancing sleep quality (Hedges g=0.56, 95% CI 0.24-0.88; P<.001). eHealth-based psychosocial interventions had significantly larger effects (P=.01) on alleviating insomnia severity in clinical samples than in subclinical samples. eHealth-based psychosocial interventions that incorporated guidance from trained therapists had a significantly greater effect on insomnia severity (P=.05) and sleep quality (P=.02) than those with guidance from animated therapists or no guidance. Higher baseline insomnia severity and longer intervention duration were associated with a larger reduction in insomnia severity (P=.004). eHealth-based psychosocial interventions significantly improved each secondary outcome. CONCLUSIONS: eHealth interventions for insomnia are effective in improving sleep and mental health and can be considered a promising treatment for insomnia. Our findings support the wider dissemination of eHealth interventions and their further promotion in a stepped-care model. Offering blended care could improve treatment effectiveness. Future research needs to elucidate which specific intervention components are most important to achieve intervention effectiveness. Blended eHealth interventions may be tailored to benefit people with low socioeconomic status, limited access to health care, or lack of eHealth literacy.

Facilitators and barriers to the implementation of improved solid fuel cookstoves and clean fuels in low-income and middle-income countries: an umbrella review.

2·6 billion people rely on solid fuels for cooking or heating. Accelerating access to cleaner solutions is crucial to reduce the negative effects of solid fuel use. Despite abundant evidence on how to implement these solutions, previous attempts have been disappointing. An overview of the evidence is missing and the translation of the evidence into practice is poor. We conducted an umbrella review using eight databases to: consolidate evidence on the factors that influence the implementation of improved solid fuel cookstoves and clean fuels in low-income and middle-income countries; weigh the level of confidence in existing evidence; and develop two practical implementation strategy tools. We identified 31 relevant reviews (13 systematic reviews and 18 narrative reviews) that covered over 479 primary studies. We found 15 implementation factors supported by the highest level of evidence. Regarding improved solid fuel cookstoves, these factors included: cost; knowledge and beliefs about the innovation; and compatibility. For clean fuels these factors included: cost; knowledge and beliefs about the innovation; and external policy and incentives. The factors were synthesised into the Cleaner Cookstove Implementation Tool and the Clean Fuel Implementation Tool. These tools can be used to optimise the implementation of cleaner cooking solutions, thereby improving health, environmental, climate, and gender equity outcomes.

Digital tools/eHealth to support CKD self-management: A qualitative study of perceptions, attitudes and needs of patients and health care professionals in China.

BACKGROUND: A growing body of evidence supports the potential effectiveness of electronic health (eHealth) self-management interventions in improving disease self-management skills and health outcomes of patients suffering from chronic kidney disease (CKD). However, current research on CKD eHealth self-management interventions has almost exclusively focused on high-income, western countries. OBJECTIVE: To inform the adaptation of a tailored eHealth self-management intervention for patients with CKD in China based on the Dutch Medical Dashboard (MD) intervention, we examined the perceptions, attitudes and needs of Chinese patients with CKD and health care professionals (HCPs) towards eHealth based (self-management) interventions in general and the Dutch MD intervention in specific. METHODS: We conducted a basic interpretive, cross-sectional qualitative study comprising semi-structured interviews with 11 patients with CKD and 10 HCPs, and 2 focus group discussions with 9 patients with CKD. This study was conducted in the First Affiliated Hospital of Zhengzhou University in China. Data collection continued until data saturation was reached. All data were transcribed verbatim and analyzed using a framework approach. RESULTS: Three themes emerged: (1) experience with eHealth in CKD (self-management), (2) needs for supporting CKD self-management with the use of eHealth, and (3) adaptation and implementation of the Dutch MD intervention in China. Both patients and HCPs had experience with and solely mentioned eHealth to 'inform, monitor and track' as potentially relevant interventions to support CKD self-management, not those to support 'interaction' and 'data utilization'. Factors reported to influence the implementation of CKD eHealth self-management interventions included information barriers (i.e. quality and consistency of the disease-related information obtained via eHealth), perceived trustworthiness and safety of eHealth sources, clinical compatibility and complexity of eHealth, time constraints and eHealth literacy. Moreover, patients and HCPs expressed that eHealth interventions should support CKD self-management by improving the access to reliable and relevant disease related knowledge and optimizing the timeliness and quality of patient and HCPs interactions. Finally, suggestions to adaptation and implementation of the Dutch MD intervention in China were mainly related to improving the intervention functionalities and content of MD such as addressing the complexity of the platform and compatibility with HCPs' workflows. CONCLUSIONS: The identified perceptions, attitudes and needs towards eHealth self-management interventions in Chinese settings should be considered by researchers and intervention developers to adapt a tailored eHealth self-management intervention for patients with CKD in China. In more detail, future research needs to engage in co-creation processes with vulnerable groups during eHealth development and implementation, increase eHealth literacy and credibility of eHealth (information resource), ensure eHealth to be easy to use and well-integrated into HCPs' workflows.

Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data.

OBJECTIVES: Dry powder inhalers (DPIs) and soft mist inhalers have a substantially lower global warming potential than pressurised metered-dose inhalers (pMDIs). To help mitigate climate change, we assessed the potential emission reduction in CO2 equivalents when replacing pMDIs by non-propellant inhalers (NPIs) in Dutch respiratory healthcare and estimated the associated cost. DESIGN: We performed a descriptive analysis of prescription data from two national databases of two independent governmental bodies. First, we calculated the number of patients with chronic obstructive pulmonary disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of pMDIs and NPIs including DPIs and soft mist inhalers, as well as the number of dispensed spacers per patient (2020). Third, we estimated the potential emission reduction in CO2 equivalents if 70% of patients would switch from using pMDIs to using NPIs. Fourth, we performed a budget impact analysis. SETTING: Dutch respiratory healthcare. PRIMARY AND SECONDARY OUTCOME MEASURES: The carbon footprint of current inhalation medication and the environmental and financial impact of replacing pMDIs with NPIs. RESULTS: In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 364 million defined daily doses from inhalers were dispensed of which 49.6% were dispensed through pMDIs. We estimated that this could be reduced by 70% which would lead to an annual reduction in greenhouse gas emission of 63 million kg.CO2 equivalents saving at best EUR 49.1 million per year. CONCLUSIONS: In the Netherlands, substitution of pMDIs to NPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing greenhouse gas emission by 63 million kg.CO2 equivalents on average and saving at best EUR 49.1 million per year. This study confirms the potential climate and economic benefit of delivering a more eco-friendly respiratory care.

Beliefs, Perceptions, and Behaviors Regarding Chronic Respiratory Diseases of Roma in Crete, Greece: A Qualitative FRESH AIR Study.

Background: The global burden of chronic respiratory diseases (CRDs) disproportionally affects Roma populations. Health interventions addressing CRD among Roma or other vulnerable groups often fail to be effective, as their implementation strategy misaligns with the local context. To design context-driven strategies, we studied CRD-related beliefs, perceptions, and behaviors among a Greek Roma population, focussing on asthma and COPD. Methods: For this qualitative study in Crete, Greece, we used a Rapid Assessment Process. We conducted interviews and focus groups with purposively selected Roma community members (CMs), key informants (KIs) and healthcare professionals (HPs) serving the population. Data were triangulated using observations of households and clinical consultations. Key themes were identified using Thematic Content Analysis. The Health Belief Model, the Explanatory Model of Illness, and the Theory of Planned Behavior that are complementary is some aspects, guided our methodology with the several variables from them to be integrated to better understand CRD risk preventative behavior. Results: We conducted six focus groups, seven interviews and 13 observations among 15 CMs, four KIs, and three HPs. Five themes emerged: (1) Poor CRD-awareness (smoking and household air pollution were perceived as harmful, but almost exclusively associated with acute rather than chronic symptoms); (2) Low perceived susceptibility to CRD (and CMs tended to ignore respiratory symptoms); (3) High risk exposure (smoking was common, and air pollution was perceived inevitable due to financial constraints); (4) Healthcare seeking (healthcare was sought only for persistent, severe symptoms, daily needs were a priority); (5) Perceived barriers/facilitators to care (health illiteracy, perceived discrimination and financial constraints were main barriers; established trust the main facilitator). Conclusion: These five themes highlight that strategies to tackle CRD in the studied Roma setting require a multilevel approach: bridging awareness gaps at the population level, providing resources to enhance the adoption of healthy behaviors, and fighting discrimination at the societal level, whilst establishing trusted relationships at the local level. Similar methodologies to address local context may strengthen the implementation of effective interventions for similarly vulnerable and/or low-resource populations.

Mapping low-resource contexts to prepare for lung health interventions in four countries (FRESH AIR): a mixed-method study.

BACKGROUND: Effectiveness of health programmes can be undermined when the implementation misaligns with local beliefs and behaviours. To design context-driven implementation strategies, we explored beliefs and behaviours regarding chronic respiratory disease (CRD) in diverse low-resource settings. METHODS: This observational mixed-method study was conducted in Africa (Uganda), Asia (Kyrgyzstan and Vietnam) and Europe (rural Greece and a Roma camp). We systematically mapped beliefs and behaviours using the SETTING-tool. Multiple qualitative methods among purposively selected community members, health-care professionals, and key informants were triangulated with a quantitative survey among a representative group of community members and health-care professionals. We used thematic analysis and descriptive statistics. FINDINGS: We included qualitative data from 340 informants (77 interviews, 45 focus group discussions, 83 observations of community members' households and health-care professionals' consultations) and quantitative data from 1037 community members and 204 health-care professionals. We identified three key themes across the settings; namely, (1) perceived CRD identity (community members in all settings except the rural Greek strongly attributed long-lasting respiratory symptoms to infection, predominantly tuberculosis); (2) beliefs about causes (682 [65·8%] of 1037 community members strongly agreed that tobacco smoking causes symptoms, this number was 198 [19·1%] for household air pollution; typical perceived causes ranged from witchcraft [Uganda] to a hot-cold disbalance [Vietnam]); and (3) norms and social structures (eg, real men smoke [Kyrgyzstan and Vietnam]). INTERPRETATION: When designing context-driven implementation strategies for CRD-related interventions across these global settings, three consistent themes should be addressed, each with common and context-specific beliefs and behaviours. Context-driven strategies can reduce the risk of implementation failure, thereby optimising resource use to benefit health outcomes. FUNDING: European Commission Horizon 2020. TRANSLATIONS: For the Greek, Russian and Vietnamese translations of the abstract see Supplementary Materials section.

Clinical Characteristics, Treatment Patterns and Economic Burden of COPD in Kyrgyzstan: A FRESH AIR Study.

BACKGROUND: COPD prevalence and mortality in Kyrgyzstan are high. Data on clinical and economic impact of COPD in Kyrgyzstan are scarce. This study was part of the FRESH AIR research project that focused on prevention, diagnosis and treatment of chronic lung diseases in low-resource settings. AIM: We aimed to evaluate the clinical characteristics, treatment patterns and economic burden of COPD in Kyrgyzstan. METHODS: A representative sample of patients with a spirometry-confirmed diagnosis of COPD was included. All patients were registered in one of the five major hospitals in Kyrgyzstan. Patients were surveyed on COPD risk factors, health-care utilization and patient reported outcomes (CCQ, MRC). Associations with high symptom burden (MRC score ≥4) and cost were assessed using logistic regression analyses. RESULTS: A total of 306 patients were included with mean age 62.1 (SD: 11.2), 61.4% being male, mean BMI 26.9 (SD: 5.2) and mean monthly income $85.1 (SD: 75.4). Biomass was used for heating and cooking by 71.2% and 52.0%. Current and ex-smokers accounted 14.1% and 32%. Mean FEV1 was 46% (SD: 12.8), 71.9% had COPD GOLD III-IV and most frequent co-morbidities were hypertension (25.2%), diabetes (5.6%) and heart diseases (4.6%). Mean CCQ score was 2.0 (SD: 0.9) and MRC score 3.7 (SD: 0.9). Yearly mean number of hospital days due to COPD was 10.1 (SD: 3.9). Total annual per-patient costs of reimbursed health-care utilization ($107) and co-payments ($224, ie, 22% of patients' annual income) were $331. We found that only GOLD IV and hypertension were significantly associated with high symptom burden. Exacerbations and hypertension were significantly associated with high cost. CONCLUSION: The clinical and economic burden of COPD on patients and the government in Kyrgyzstan is considerable. Notably, almost half of interviewed patients were current or ex-smokers and biomass exposure was high.

Music and dance in respiratory disease management in Uganda: a qualitative study of patient and healthcare professional perspectives.

INTRODUCTION: Music and dance are increasingly used as adjunctive arts-in-health interventions in high-income settings, with a growing body of research suggesting biopsychosocial benefits. Such low-cost, low-resource interventions may have application in low-resource settings such as Uganda. However, research on perceptions of patients and healthcare professionals regarding such approaches is lacking. METHODS: We delivered sample sessions of music and dance for chronic respiratory disease (CRD) to patients and healthcare professionals. Seven participants took part in one singing and dance sample session. One patient completed only the dance session. We then conducted an exploratory qualitative study using thematic analysis of semistructured interviews with healthcare professionals and patients regarding (1) the role of music and dance in Ugandan life and (2) the perceived acceptability and feasibility of using music and dance in CRD management in Uganda. RESULTS: We interviewed 19 participants, made up of 11 patients with long-term respiratory conditions and 8 healthcare professionals, who were selected by purposeful convenience sampling. Four key themes were identified from interview analysis: music and dance (1) were central components of daily life; (2) had an established role supporting health and well-being; and (3) had strong therapeutic potential in respiratory disease management. The fourth theme was (4) the importance of modulating demographic considerations of culture, religion and age. CONCLUSION: Music and dance are central to life in Uganda, with established roles supporting health and well-being. These roles could be built on in the development of music and dance interventions as adjuncts to established components of CRD disease management like pulmonary rehabilitation. Through consideration of key contextual factors and codevelopment and adaptation of interventions, such approaches are likely to be well received.

Chronic respiratory disease surveys in adults in low- and middle-income countries: A systematic scoping review of methodological approaches and outcomes.

BACKGROUND: Chronic respiratory diseases (CRDs) contribute significantly towards the global burden of disease, but the true prevalence and burden of these conditions in adults is unknown in the majority of low- and middle-income countries (LMICs). We aimed to identify strategies - in particular the definitions, study designs, sampling frames, instruments, and outcomes - used to conduct prevalence surveys for CRDs in LMICs. The findings will inform a future RESPIRE Four Country ChrOnic Respiratory Disease (4CCORD) study, which will estimate CRD prevalence, including disease burden, in adults in LMICs. METHODS: We conducted a scoping review to map prevalence surveys conducted in LMICs published between 1995 and 2018. We followed Arksey and O'Malley's six-step framework. The search was conducted in OVID Medline, EMBASE, ISI Web of Science, Global Health, WHO Global Index Medicus and included three domains: CRDs, prevalence and LMICs. After an initial title sift, eight trained reviewers undertook duplicate study selection and data extraction. We charted: country and populations, random sampling strategies, CRD definitions/phenotypes, survey procedure (questionnaires, spirometry, tests), outcomes and assessment of individual, societal and health service burden of disease. RESULTS: Of 36 872 citations, 281 articles were included: 132 from Asia (41 from China). Study designs were cross-sectional surveys (n = 260), cohort studies (n = 11) and secondary data analysis (n = 10). The number of respondents in these studies ranged from 50 to 512 891. Asthma was studied in 144 studies, chronic obstructive pulmonary disease (COPD) in 112. Most studies (100/144) based identification of asthma on symptom-based questionnaires. In contrast, COPD diagnosis was typically based on spirometry findings (94/112); 65 used fixed-ratio thresholds, 29 reported fixed-ratio and lower-limit-of-normal values. Only five articles used the term 'phenotype'. Most studies used questionnaires derived from validated surveys, most commonly the European Community Respiratory Health Survey (n = 47). The burden/impact of CRD was reported in 33 articles (most commonly activity limitation). CONCLUSION: Surveys remain the most practical approach for estimating prevalence of CRD but there is a need to identify the most predictive questions for diagnosing asthma and to standardise diagnostic criteria.

A systematic approach to context-mapping to prepare for health interventions: development and validation of the SETTING-tool in four countries.

Effectiveness of health interventions can be substantially impaired by implementation failure. Context-driven implementation strategies are critical for successful implementation. However, there is no practical, evidence-based guidance on how to map the context in order to design context-driven strategies. Therefore, this practice paper describes the development and validation of a systematic context-mapping tool. The tool was cocreated with local end-users through a multistage approach. As proof of concept, the tool was used to map beliefs and behaviour related to chronic respiratory disease within the FRESH AIR project in Uganda, Kyrgyzstan, Vietnam and Greece. Feasibility and acceptability were evaluated using the modified Conceptual Framework for Implementation Fidelity. Effectiveness was assessed by the degree to which context-driven adjustments were made to implementation strategies of FRESH AIR health interventions. The resulting Setting-Exploration-Treasure-Trail-to-Inform-implementatioN-strateGies (SETTING-tool) consisted of six steps: (1) Coset study priorities with local stakeholders, (2) Combine a qualitative rapid assessment with a quantitative survey (a mixed-method design), (3) Use context-sensitive materials, (4) Collect data involving community researchers, (5) Analyse pragmatically and/or in-depth to ensure timely communication of findings and (6) Continuously disseminate findings to relevant stakeholders. Use of the tool proved highly feasible, acceptable and effective in each setting. To conclude, the SETTING-tool is validated to systematically map local contexts for (lung) health interventions in diverse low-resource settings. It can support policy-makers, non-governmental organisations and health workers in the design of context-driven implementation strategies. This can reduce the risk of implementation failure and the waste of resource potential. Ultimately, this could improve health outcomes.

Factors critical to implementation success of cleaner cooking interventions in low-income and middle-income countries: protocol for an umbrella review.

INTRODUCTION: Over a third of the world's population relies on solid fuels as their primary energy source. These fuels have damaging effects on health, air quality and forest resources. Interventions to promote access to cleaner solid fuel cookstoves and clean fuels have existed for decades. However, the adoption by local communities has largely failed, which led to a waste of resources and suboptimal outcomes. Therefore, the objective of this umbrella review is to identify factors that determine implementation success for cleaner cooking interventions in low-resource settings and weigh their level of confidence in the evidence. METHODS AND ANALYSIS: We identified systematic and narrative reviews examining factors that influence the acquisition, initial adoption or sustained use of cleaner solid fuel cookstoves and clean fuels at any scale by a literature search in PubMed, Embase, Global Health Database, Cochrane, PsycINFO, Emcare, Web of Science and CINAHL, without date or language restrictions. The search was conducted on 23 October 2017 and updated on 10 July 2019. Reviews based on qualitative, quantitative or mixed-methods studies were included and will be appraised using the Meta Quality Appraisal Tool combined with the Assessment of Multiple Systematic Reviews. Data will be extracted and factors affecting implementation will be coded using the Consolidated Framework for Implementation Research. The Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research tool will be used to determine the level of confidence in the coded factors. Two researchers will independently conduct these steps. ETHICS AND DISSEMINATION: This umbrella review does not require the approval of an ethical review board. Study results will be published in an international peer-reviewed journal. The outcomes will be converted into two practical tools: one for cleaner solid fuel cookstoves and one for clean fuels. These tools can guide the development of evidence-based implementation strategies for cleaner cooking interventions in low-income and middle-income countries to improve implementation success. These tools should be pilot-tested and promoted among regional and global initiatives. PROSPERO REGISTRATION NUMBER: CRD42018088687.

Publisher Correction: Implementing a context-driven awareness programme addressing household air pollution and tobacco: a FRESH AIR study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Implementing a context-driven awareness programme addressing household air pollution and tobacco: a FRESH AIR study.

Most patients with chronic respiratory disease live in low-resource settings, where evidence is scarcest. In Kyrgyzstan and Vietnam, we studied the implementation of a Ugandan programme empowering communities to take action against biomass and tobacco smoke. Together with local stakeholders, we co-created a train-the-trainer implementation design and integrated the programme into existing local health infrastructures. Feasibility and acceptability, evaluated by the modified Conceptual Framework for Implementation Fidelity, were high: we reached ~15,000 Kyrgyz and ~10,000 Vietnamese citizens within budget (~€11,000/country). The right engaged stakeholders, high compatibility with local contexts and flexibility facilitated programme success. Scores on lung health awareness questionnaires increased significantly to an excellent level among all target groups. Behaviour change was moderately successful in Vietnam and highly successful in Kyrgyzstan. We conclude that contextualising the awareness programme to diverse low-resource settings can be feasible, acceptable and effective, and increase its sustainability. This paper provides guidance to translate lung health interventions to new contexts globally.

Implementing lung health interventions in low- and middle-income countries: a FRESH AIR systematic review and meta-synthesis.

The vast majority of patients with chronic respiratory disease live in low- and middle-income countries (LMICs). Paradoxically, relevant interventions often fail to be effective particularly in these settings, as LMICs lack solid evidence on how to implement interventions successfully. Therefore, we aimed to identify factors critical to the implementation of lung health interventions in LMICs, and weigh their level of evidence.This systematic review followed Cochrane methodology and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) reporting standards. We searched eight databases without date or language restrictions in July 2019, and included all relevant original, peer-reviewed articles. Two researchers independently selected articles, critically appraised them (using Critical Appraisal Skills Programme (CASP)/Meta Quality Appraisal Tool (MetaQAT)), extracted data, coded factors (following the Consolidated Framework for Implementation Research (CFIR)), and assigned levels of confidence in the factors (via Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)). We meta-synthesised levels of evidence of the factors based on their frequency and the assigned level of confidence (PROSPERO:CRD42018088687).We included 37 articles out of 9111 screened. Studies were performed across the globe in a broad range of settings. Factors identified with a high level of evidence were: 1) "Understanding needs of local users"; 2) ensuring "Compatibility" of interventions with local contexts (cultures, infrastructures); 3) identifying influential stakeholders and applying "Engagement" strategies; 4) ensuring adequate "Access to knowledge and information"; and 5) addressing "Resource availability". All implementation factors and their level of evidence were synthesised in an implementation tool.To conclude, this study identified implementation factors for lung health interventions in LMICs, weighed their level of evidence, and integrated the results into an implementation tool for practice. Policymakers, non-governmental organisations, practitioners, and researchers may use this FRESH AIR (Free Respiratory Evaluation and Smoke-exposure reduction by primary Health cAre Integrated gRoups) Implementation tool to develop evidence-based implementation strategies for related interventions. This could increase interventions' implementation success, thereby optimising the use of already-scarce resources and improving health outcomes.

The socioeconomic burden of chronic lung disease in low-resource settings across the globe - an observational FRESH AIR study.

BACKGROUND: Low-resource settings are disproportionally burdened by chronic lung disease due to early childhood disadvantages and indoor/outdoor air pollution. However, data on the socioeconomic impact of respiratory diseases in these settings are largely lacking. Therefore, we aimed to estimate the chronic lung disease-related socioeconomic burden in diverse low-resource settings across the globe. To inform governmental and health policy, we focused on work productivity and activity impairment and its modifiable clinical and environmental risk factors. METHODS: We performed a cross-sectional, observational FRESH AIR study in Uganda, Vietnam, Kyrgyzstan, and Greece. We assessed the chronic lung disease-related socioeconomic burden using validated questionnaires among spirometry-diagnosed COPD and/or asthma patients (total N = 1040). Predictors for a higher burden were studied using multivariable linear regression models including demographics (e.g. age, gender), health parameters (breathlessness, comorbidities), and risk factors for chronic lung disease (smoking, solid fuel use). We applied identical models per country, which we subsequently meta-analyzed. RESULTS: Employed patients reported a median [IQR] overall work impairment due to chronic lung disease of 30% [1.8-51.7] and decreased productivity (presenteeism) of 20.0% [0.0-40.0]. Remarkably, work time missed (absenteeism) was 0.0% [0.0-16.7]. The total population reported 40.0% [20.0-60.0] impairment in daily activities. Breathlessness severity (MRC-scale) (B = 8.92, 95%CI = 7.47-10.36), smoking (B = 5.97, 95%CI = 1.73-10.22), and solid fuel use (B = 3.94, 95%CI = 0.56-7.31) were potentially modifiable risk factors for impairment. CONCLUSIONS: In low-resource settings, chronic lung disease-related absenteeism is relatively low compared to the substantial presenteeism and activity impairment. Possibly, given the lack of social security systems, relatively few people take days off work at the expense of decreased productivity. Breathlessness (MRC-score), smoking, and solid fuel use are potentially modifiable predictors for higher impairment. Results warrant increased awareness, preventive actions and clinical management of lung diseases in low-resource settings from health policymakers and healthcare workers.