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Barriers to the Identification of Occupational Asthma

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Barriers to the Identification of Occupational Asthma BARRIERS TO THE IDENTIFICATION OF OCCUPATIONAL ASTHMA By Gareth Iestyn Walters A thesis submitted to The University of Birmingham for the degree of Doctor of Medicine School of Health and Populations Sciences College of Medical and Dental Sciences The University of Birmingham August 2014 DEDICATION This is for my father Derek Walters (1940-2011)… who would have kept a copy on the bookshelf, but probably wouldn’t have read it unless it was about Frederick the Great or the Stuart monarchy… which unfortunately it isn’t. ABSTRACT Occupational asthma accounts for 1 in 6 cases of new-onset adult asthma and is associated with an estimated societal cost in the UK of £100 million per annum. The cost is somewhat avoidable if workers with occupational asthma are identified quickly and removed from exposure to a sensitizing agent. However many workers with occupational asthma go undiagnosed or experience a lengthy delay in diagnosis. The aim of this work was to identify the barriers to diagnosis of occupational asthma on the part of the worker and of the healthcare professional. The first study evaluated current practice in assessing working-age asthmatics for occupational asthma in a West Midlands primary care population, using UK national guidelines as a reference standard. The recorded prevalence of occupational asthma was much lower than expected (0-0.8%) and there was poor enquiry regarding occupation (14% of cases) and the effect of work on asthma symptoms (2% of cases) by primary healthcare professionals. The second study used a qualitative methodology to explore and define health beliefs and behaviours in workers with occupational asthma symptoms. The major influences on workers’ health seeking behavior were determined from four themes: (1) workers’ understanding of their symptoms, (2) working relationships, (3) workers’ course of action with symptoms and (4) workers’ negotiation with healthcare professionals. The third study aimed to define the important barriers to identifying occupational asthma from the point of view of healthcare professionals. High levels of enquiry about the nature of patients’ work and work-relatedness of symptoms were reported by GPs, nurses and non-occupational lung specialist physicians, though the sample was biased towards enthusiasts. Despite this, low awareness and adherence to occupational asthma guidelines was evident in all non-specialist groups. The fourth study evaluated the feasibility of introducing an electronic occupational asthma screening tool for primary care. Healthcare professionals who used the tool found it to be quick and easy to implement and user-friendly (clear, concise, logical), without impacting on the length of a consultation. With adequate training for users the screening tool could be rolled out nationwide in the UK and its clinical effectiveness measured. iii ACKNOWLEDGEMENTS I owe great thanks to Professor Jon Ayres for his support from the outset, to Professor David Fitzmaurice for stepping in at just the right time, and to Sherwood Burge, Alastair Robertson and Vicky Moore for words of encouragement throughout. CHAPTER 3 I am grateful to Jacqueline Ingram (Primary Care Clinical Research and Trials Unit, University of Birmingham) and practice research nurses from each of four Birmingham Primary Care Research Network practices, for their clinical insights and assistance with practice recruitment in this study. CHAPTER 4 I would like to thank Dr. Andy Soundy in the School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham for generously giving his time for expert supervision in qualitative research, and the workers who volunteered to prolong their hospital visits in order to undertake interviews, some of whom had travelled many miles for a clinic appointment. CHAPTER 5 I am grateful to the following individuals for enabling organizational sponsorship and for distributing the questionnaire study via e-mail: Hilary Todd, Angela Burnett (Society of Occupational Medicine), John Rafferty (Faculty of Occupational Medicine), Tricia Bryant (Primary Care Respiratory Society-UK), Rebecca Sherrington, Angela Hurlstone (Association of Respiratory Specialist Nurses), Gill Brown, Jane Hind (Royal College of Physicians regional faculties), Angela Thomas, Anna Reid, Sue Caller, Linda Thorogood, Fiona Brennan (Royal College of General Practitioners regional faculties), Tobias Ginsberg, Clare McGovern, Susan George, Rosemarie Atkins (Postgraduate Workforce Deaneries). I also iv wish to thank Professor Jerry Beach (University of Alberta, Edmonton, Canada) and co- authors for giving permission to use their work causation scenarios. CHAPTER 6 I am grateful to the following individuals whose willingness to get involved enabled recruitment of practices to the feasibility study in primary care: Dr. Raj Ramachandram, Dr. Hunaid Rashiq, Dr. Will Taylor, Dr. Kevin Woollaston. I would also like to thank Dr. Karla Hemming in the Department of Public Health, Epidemiology and Biostatistics, University of Birmingham who regularly gave her time at the outset of this work to discuss measuring clinical effectiveness of a screening tool for occupational asthma. v CONTENTS Page number Abstract ………………………………………………………………….……………..… iii Acknowledgements ………………………………………………………………………. iv Contents ………………………………………………………………………………….. vi List of Figures …………………………………………………………............................. xiii List of Tables …………………………………………………………………….............. xv Abbreviations …………………………………………………………………………...... xvii CHAPTER 1: INTRODUCTION 1.1 Defining occupational asthma 1.1.1 Overview ……………………………………………………………………. 1 1.1.2 Occupational asthma by sensitization ………………………………………. 3 1.1.3 Irritant-induced asthma ……………………………………………………… 5 1.1.4 Differential diagnosis of occupational asthma ……………………………… 6 1.1.5 Occupational asthma guidelines …………………………………….............. 7 1.2 Epidemiology of occupational asthma 1.2.1 Reporting schemes …………………………………………………………... 8 1.2.2 Incidence data ………………………………………………………………... 9 1.2.3 Under-reporting of occupational asthma …………………………………….. 11 1.2.4 Incidence trends ……………………………………………………………... 12 1.2.5 Under-recognition in primary care …………………………………………... 14 1.2.6 Occupational risk factors ……………………………………………………. 16 1.2.7 Other risk factors ………………………………………………………….…. 18 1.3 Diagnosis of occupational asthma 1.3.1 Expert opinion ……………………………………………………………….. 19 1.3.2 Questionnaires ………………………………………………………………... 20 vi 1.3.3 Serial peak-expiratory flow measurements …………………………………. 21 1.3.4 Peak-expiratory flow analysis ………………………………………………. 22 1.3.5 Software analysis of peak-expiratory flow measurements ………………….. 24 1.3.6 Cross-shift changes in peak expiratory flow and FEV1 ……………………... 26 1.3.7 Specific inhalation challenge testing …...…………………………………… 26 1.3.8 Non-specific bronchial reactivity ……………………………………………. 29 1.3.9 Paired measurements of non-specific bronchial reactivity ………….……….. 29 1.3.10 Sputum eosinophilia ……………………………………………………….. 30 1.3.11 Fractional exhaled nitric oxide ……………………………………………... 31 1.3.12 Specific IgE to occupational agents ………………………………………… 33 1.3.13 Occupational health surveillance……………………………………………. 34 1.4 Outcomes of occupational asthma 1.4.1 Health economics ……………………………………………………………. 35 1.4.2 Socio-economic outcomes for the worker …………………………………… 36 1.4.3 Health outcomes for the worker ……………………………………………… 37 1.5 Conclusion ……………………………………………………………………………. 39 CHAPTER 2: AIMS AND OBJECTIVES 2.1 Background …………………………………………………………………………… 41 2.2 Overall aim of research ……………………………………………………………….. 41 2.3 Hypotheses ……………………………………………………………………………. 41 2.4 Specific objectives …………………………………………………………………….. 42 CHAPTER 3: ASSESSMENT FOR OCCUPATIONAL ASTHMA IN PRIMARY CARE 3.1 Introduction …………………………………………………………………………… 44 3.2 Aim ……………………………………………………………………………………. 45 3.3 Methods 3.3.1 Study design ………………………………………………………………….. 45 vii 3.3.2 Practice recruitment ………………………………………………………….. 45 3.3.3 Practice-level data ……………………………………………………………. 45 3.3.4 Sample data …………………………………………………………………... 45 3.4 Results 3.4.1 Practice-level data ……………………………………………………….…… 46 3.4.2 Sample data …………………………………………………………………... 48 3.4.3 Recording occupation and work effect ………………………………………. 50 3.5 Discussion 3.5.1 Summary ……………………………………………………………………… 51 3.5.2 Limitations ………………………………………………………….………… 51 3.5.3 Prevalence of occupational asthma …………………………………………… 53 3.5.4 Recording occupation ………………………………………………………… 53 3.5.5 Recording work effect ………………………………………………………... 55 3.5.6 Context of findings …………………………………………….……………... 56 3.6 Conclusion . ……………………………………………….…………………………... 57 CHAPTER 4: UNDERSTANDING HEALTH BELIEFS AND BEHAVIOUR IN WORKERS WITH OCCUPATIONAL ASTHMA 4.1 Introduction ……………………………………………………….…………………… 58 4.2 Aim …………………………………………………………………..………………… 59 4.3 Qualitative research ……………………………………………….…………………… 59 4.4 Methods 4.4.1 Study design …………………………...……………………………………… 60 4.4.2 Setting …………………..………………………...…………………………... 60 4.4.3 Eligibility criteria ……………………………………………………………... 60 4.4.4 Sample selection ………………….…………………………………………... 60 4.4.5 Participant recruitment ……………..………………….………………………60 4.4.6 Data collection ………………………………………………………………... 61 viii 4.4.7 Data transcription …………….……………………………..…………………61 4.4.8 Thematic analysis ………………………..…………………………………… 62 4.4.9 Reflexivity ……………….…………………………………………………… 63 4.4.10 Ethical approval ………………..……………………………………………. 64 4.5 Results 4.5.1 Descriptive analysis ……….………………….………………………………. 64 4.5.2 Qualitative analysis 4.5.2.1 Theme 1: The worker’s understanding of his/her symptoms
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