Table 2

Examples of major context-driven changes to the FRESH AIR intervention planning and implementation strategies

Theoretical factors*Contextual inputContext-driven adaptations
Perceived identity of CRDAwareness on CRDs and their implications was considerably lower than anticipated among rural communities and their healthcare professionals in Uganda, Kyrgyzstan and Vietnam.For the Online Spirometry Trainings to improve knowledge and skills successfully, either the video content had to be adapted fundamentally to be compatible with a more basic level of understanding of CRD, or the trainings needed to be implemented in areas where the level of understanding was higher. In agreement with the stakeholders, we chose the latter strategy.
Perceived causes/ susceptibility/ cue to actionAwareness on the risk of household air pollution was low in Uganda, Kyrgyzstan and Vietnam; communities did not perceive their traditional cooking habits to be a risk for CRD, and therefore perceived no need for cleaner cooking measures.The Awareness Programme on CRDs was expanded: the delivery strategy turned into a cascading train-the-trainer programme with a larger reach.56 Household air pollution as a risk factor to lung health was covered extensively, creating a locally perceived need for cleaner cooking interventions. This contributed substantially to a high acceptability of the interventions (Cleaner Cooking and a Midwife-led Smoke-reduction Programme).57 58
Perceived causes/ benefits/ normsA (rural) Kyrgyz norm is that ‘a real man smokes’, while smoking women are despised. The risk of smoke exposure during pregnancy is fairly unknown, and the man’s position in the family does not allow to question his smoking behaviour. Meanwhile, the youngest son in the family is responsible for taking care of his parents later in life (the families’ pension).In the Kyrgyz Awareness Programme, we emphasised even more on the risk of smoke exposure to (unborn) children, and provided solutions to secondhand smoke exposure (smoking cessation, smoking outdoors).56 This promoted openness to the Awareness Programme and uptake of the Smoking Cessation Counselling intervention (very brief advice).59
Perceived causes/ susceptibilityThe Vietnamese word for ‘overwork’ (Lao Lu’c) resembled the word for ‘tuberculosis’ (Lao), and so communities and their healthcare professionals often associated exercise, including pulmonary rehabilitation, with lung impairment.To overcome the hesitance of patients to participate in the Pulmonary Rehabilitation Programme,60 we had to introduce a component in the programme that emphasised the benefits of exercise for respiratory symptoms.
Norms/ barriersWe had planned to also address the Roma population in Greece with our interventions, yet our RAP provided us the insight that this population was extremely hard-to-reach; working with the Roma would require years of trust, which was beyond the scope of our 3 year research and funding period.To use our resources more effectively in Greece, we decided to prioritise solely on the rural, traditional Greek population (low-resource, rural populations) instead.
Norms/ cue to actionIn rural Greece, brotherhood (filotimo) was a prevailing norm: connecting with and helping those around you was highly valued.We embraced this norm as a motivator in the Pulmonary Rehabilitation Programme.60 We capitalised on the positive social pressure to exercise together as a group and help each other to complete the programme by not missing a single training. The programme in Greece had almost no drop-outs.
  • *In many examples, multiple factors of our composed theoretical framework would apply to the contextual input. The factors with highest applicability are reported.

  • CRD, chronic respiratory disease; RAP, rapid assessment process.;