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

Abstract

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.

Keywords: Chronic lung disease; Chronic respiratory disease; Health economics; Household air pollution; Low-income population; Low-resource countries; Obstructive lung disease; WPAI; Work.

Fig. 1

Recruitment of study participants. CLD = chronic lung disease. *In Greece and Kyrgyzstan, the exact number was not registered during the process. †Participants were excluded from the analysis if the outcome ‘activity impairment’ was missing

Fig. 2

Work productivity and activity impairment due to CLD. CLD = chronic lung disease; WPAI = work productivity and activity impairment in median [interquartile range] %. 100% means maximum impairment. Total number of participants (numbers of employed population): Uganda N = 173 (81), Vietnam 471 (134), Kyrgyzstan 306 (40), Greece 90 (15), and total 1040 (270). Due to different population characteristics per country, data should be interpreted within the country’s context and not be used to directly compare between countries

Fig. 3

Multivariable regressions per country. Mean unstandardized B (95%CI). MRC = medical research council breathlessness scale (ranging 1-5). Age (years). a Uganda, b Vietnam, c Kyrgyzstan, d Greece

Fig. 4

Total multivariable regression. Mean unstandardized B (95%CI). MRC = medical research council breathlessness scale (1-5). Age (years)

Fig. 5

WPAI and MRC-score. MRC = medical research council breathlessness scale (ranging 1-5). WPAI = work productivity and activity impairment in median %. Left: Activity impairment per MRC-score per country; Uganda N = 172 (1 missing MRC value), Vietnam N = 471, Kyrgyzstan N = 306, Greece N = 90, and total N = 10. Due to different population characteristics per country, data should be interpreted within the country’s context and not be used to directly compare between countries. Right: WPAI per MRC-score; Absenteeism N = 260, presenteeism N = 268, overall work impairment N = 259, activity impairment (270), total activity impairment N = 1039