ABSTRACT

The knowledge deficit of health professionals has been a barrier to expanding and implementing of pulmonary rehabilitation (PR) services, despite the reported benefits of PR for individuals with Chronic Respiratory Disease (CRD). This study aims to assess the preparedness of health care professionals from two Brazilian cities to perform PR in the public health system. This is survey is part of a larger project to implement PR in the Brazilian public health system. A self-administered questionnaire was used to assess the knowledge (19 questions), training (7 questions), confidence (10 questions), and clinical experience (8 questions) of physical therapists (PT) and the multiprofessional team (MT) before a PR workshop. In total, 44 PT and 231 MT answered the questionnaire. The mean total knowledge score was 10±3 for PT and 6±3 for MT. Few physical therapist reported having “a lot” of experience (25%) and confidence (22.7%) to perform PR, as well as sufficient training to conduct the six-minute walk test (27.3%).Even fewer MT reported having “a lot” of experience (10%) and sufficient training (4.8%) to perform PR, as well as to plan the educational program for patients (10%) and the confidence to refer patients to PR (6.5%). This is the first study to evaluate the preparedness of professionals from the Brazilian public health network to provide PR. Notably, both PT and MT have low preparation to perform PR in the studied cities, reinforcing the need for continuing education.

Keywords |
Lung diseases; Chronic Obstructive Pulmonary Disease; Rehabilitation; Physical Therapists; Health Care Professional

RESUMEN

El déficit de conocimientos entre los profesionales de la salud ha sido una barrera para la expansión e implementación de los servicios de rehabilitación pulmonar (RP) a pesar de sus beneficios comprobados para las personas con enfermedad respiratoria crónica (ERC). Este estudio de encuesta forma parte de un proyecto más amplio para implantar la RP en el sistema público sanitario brasileño mediante la evaluación de la preparación de los profesionales sanitarios de dos municipios brasileños para proporcionarla. Se utilizó un cuestionario autoadministrado para evaluar los conocimientos (19 preguntas), la formación (7 preguntas), la confianza (10 preguntas) y la experiencia clínica (8 preguntas) de los fisioterapeutas (FT) y del equipo multiprofesional (EM), aplicado previamente en un taller sobre RP. La puntuación media de los conocimientos fue de 10±3 para FT y de 6±3 para EM. Menos de un tercio de los FT afirmaron que tenían “mucha” experiencia (25%) y confianza (22,7%) para realizar la RP, así como formación suficiente para realizar la prueba de la marcha de seis minutos (27,3%). Pocos profesionales del EM declararon que tenían “mucha” experiencia (10%) y formación suficiente (4,8%) para realizar la RP, así como para planificar el programa educativo (10%) y tenían confianza para derivar a pacientes para la RP (6,5%). Este es el primer estudio que evalúa la preparación de los profesionales de la red pública de salud en Brasil para proporcionar la RP, y se observa que, en los municipios donde se realizó, tanto los FT como el EM están poco preparados para llevarla a cabo, lo que refuerza la necesidad de una formación continuada.

Palabras clave |
Enfermedades Pulmonares; Enfermedad Pulmonar Obstructiva Crónica; Rehabilitación; Fisioterapeutas; Profesionales de la Salud

RESUMO

O déficit de conhecimento dos profissionais de saúde tem sido uma barreira para a expansão e implementação dos serviços de reabilitação pulmonar (RP), apesar dos seus benefícios comprovados para indivíduos com doença respiratória crônica (DRC). Objetivo: avaliar o preparo dos profissionais de saúde de dois municípios brasileiros para fornecer a RP no sistema público de saúde. Esse estudo, do tipo survey, foi parte de um projeto maior para implementação da RP no sistema público de saúde brasileiro. Foi utilizado um questionário autoaplicável para avaliar o conhecimento (19 questões), o treinamento (7 questões), a confiança (10 questões) e a experiência clínica (8 questões) dos fisioterapeutas (FT) e da equipe multiprofissional (EM), aplicado antes de um workshop sobre RP. No total, 44 FT e 231 EM responderam o questionário. A pontuação média de conhecimento foi de 10±3 para FT e 6±3 para EM. Poucos FT referiam ter “muita” experiência (25%) e confiança (22,7%) para realizar RP, bem como treinamento suficiente para realizar o teste de caminhada de seis minutos (27,3%). Ainda menos profissionais da EM relataram ter “muita” experiência (10%) e treinamento suficiente (4,8%) para realizar RP, assim como para planejar o programa educacional dos pacientes (10%) e ter confiança para encaminhar pacientes para a RP (6,5%). Este é o primeiro estudo a avaliar o preparo dos profissionais da rede pública de saúde no Brasil para fornecer RP. Notavelmente, tanto FT quanto EM têm baixo preparo para realizar RP nos municípios estudados, reforçando a necessidade de realização de educação continuada.

Descritores |
Pneumopatias; Doença Pulmonar Obstrutiva Crônica; Reabilitação; Fisioterapeutas; Profissionais de Saúde

INTRODUCTION

Chronic respiratory diseases (CRD) are a worldwide health problem that can affect both the upper and lower airways. Among the CRD, chronic obstructive pulmonary disease (COPD)¹1. World Health Organization. Chronic respiratory diseases (asthma, COPD). Geneva: WHO; [2022] [cited Mar 13, 2022]. Available from: https://www.who.int/westernpacific/health-topics/chronic-respiratory-diseases
https://www.who.int/westernpacific/healt... ⁾ stands out, with a prevalence of 11.7% and causing around three million deaths worldwide every year²2. Adeloye D, Chua S, Lee C, Basquil C, Papana A, et al. Global and regional estimates of COPD prevalence: Systematic review and meta-analysis. J Glob Health. 2015;5(2):020415. doi: 10.7189/jogh.05.020415
https://doi.org/10.7189/jogh.05.020415... ^),(33. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Fontana: GOLD; 2020 [cited Sept 23, 2021]. Available from: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
https://goldcopd.org/wp-content/uploads/... . It is estimated that the prevalence of COPD will increase over the next 40 years and that, by 2060, there could be more than 5.4 million deaths attributable to COPD³3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Fontana: GOLD; 2020 [cited Sept 23, 2021]. Available from: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
https://goldcopd.org/wp-content/uploads/... ^),(44. Naghavi M, Wang H, Lozano R, Davis A, Ling X, et al. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385(9963):117-71. doi: 10.1016/S0140-6736(14)61682-2
https://doi.org/10.1016/S0140-6736(14)61... . In Brazil, the PLATINO⁵5. Moreira GL, Manzano BM, Gazzotti MR, Nascimento OA, Perez-Padilha R, et al. PLATINO, estudo de seguimento de nove anos sobre DPOC na cidade de São Paulo: O problema do subdiagnóstico. J Bras Pneumol. 2014;40(1):30-7. doi: 10.1590/S1806-37132014000100005
https://doi.org/10.1590/S1806-3713201400... study found a COPD underdiagnosis rate of 70% in a São Paulo city cohort and, in 2019, the cost to the public health system was around 25 million dollars, corresponding to 109,995 hospitalizations for COPD⁶6. Brasil. Ministério da Saúde . DATASUS. Morbidade Hospitalar do SUS - por local de internação - Brasil. Brasília, DF; c2003-2021 [cited May 3, 2021]. Available from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/niuf.def
http://tabnet.datasus.gov.br/cgi/tabcgi.... .

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) ⁽³3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Fontana: GOLD; 2020 [cited Sept 23, 2021]. Available from: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
https://goldcopd.org/wp-content/uploads/... recommends pulmonary rehabilitation (PR) as the most effective non-pharmacological treatment for people with COPD, reducing dyspnea, increasing exercise capacity and quality of life, reducing anxiety and depression, and accelerating recovery after an exacerbation³3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report). Fontana: GOLD; 2020 [cited Sept 23, 2021]. Available from: https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf
https://goldcopd.org/wp-content/uploads/... ^),(77. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, et al. An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373-86. doi: 10.1164/rccm.201510-1966ST
https://doi.org/10.1164/rccm.201510-1966... ^)-(99. Spruit MA, Pitta F, Garvey C, ZuWallack RL, Roberts CM, et al. Differences in content and organisational aspects of pulmonary rehabilitation programmes. Eur Respir J. 2014;43(5):1326-37. doi: 10.1183/09031936.00145613
https://doi.org/10.1183/09031936.0014561... .

A recent study identified 217 PR centers throughout Latin America, of which 124 were in Brazil. The number of centers in Brazil increased eightfold compared to 1988¹⁰10. Barreto GZ, Ivanaga IT, Chiavegato L, Gazzotti MR, Nascimento OA, et al. Perspective of Pulmonary Rehabilitation Centers in Latin America. COPD. 2021;18(4):401-5. doi: 10.1080/15412555.2021.1934822
https://doi.org/10.1080/15412555.2021.19... . However, considering the high prevalence of COPD, there is only one center for every 4,000 people with COPD in Brazil. These data show the need to expand this service¹⁰10. Barreto GZ, Ivanaga IT, Chiavegato L, Gazzotti MR, Nascimento OA, et al. Perspective of Pulmonary Rehabilitation Centers in Latin America. COPD. 2021;18(4):401-5. doi: 10.1080/15412555.2021.1934822
https://doi.org/10.1080/15412555.2021.19... . Despite all the benefits, PR is still underused worldwide and often inaccessible to most patients⁷7. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, et al. An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373-86. doi: 10.1164/rccm.201510-1966ST
https://doi.org/10.1164/rccm.201510-1966... ^),(99. Spruit MA, Pitta F, Garvey C, ZuWallack RL, Roberts CM, et al. Differences in content and organisational aspects of pulmonary rehabilitation programmes. Eur Respir J. 2014;43(5):1326-37. doi: 10.1183/09031936.00145613
https://doi.org/10.1183/09031936.0014561... . Evidence indicates that less than 5% of COPD patients have access to PR ¹¹11. Yohannes AM, Connolly MJ. Pulmonary rehabilitation programmes in the UK: A national representative survey. Clin Rehabil. 2004;18(4):444-9. doi: 10.1191/0269215504cr736oa
https://doi.org/10.1191/0269215504cr736o... ^)-(1313. White P, Gilworth G, Lewin S, et al. Improving uptake and completion of pulmonary rehabilitation in COPD with lay health workers: Feasibility of a clinical trial. Int J Chron Obstruct Pulmon Dis. 2019;14:631-43. doi: 10.2147/COPD.S188731
https://doi.org/10.2147/COPD.S188731... due to the limited numbers of programs and low referral rates. Some of the reasons for the low referral of patients to PR are the lack of healthcare practitioner’s training, the lack of knowledge of physicians regarding PR benefits, the lack of financial resources to provide PR programs, and inadequate structure to perform PR programs in rural or remote areas⁷7. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, et al. An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373-86. doi: 10.1164/rccm.201510-1966ST
https://doi.org/10.1164/rccm.201510-1966... ^),(1414. Johnston KN, Young M, Grimmer KA, Antic R, Frith PA. Barriers to, and facilitators for referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners : a qualitative study. Prim Care Respir J. 2013;22(3):319-24. doi: 10.4104/pcrj.2013.00062
https://doi.org/10.4104/pcrj.2013.00062... . Most people with COPD are unaware of the benefits of PR¹²12. Brook D, Sottana R, Bell B, Hanna M, Laframboise L, et al. Characterization of pulmonary rehabilitation programs in Canada in 2005. Can Respir J. 2007;14(2):87-92. doi: 10.1155/2007/951498
https://doi.org/10.1155/2007/951498... and are therefore unlikely to seek referral to PR programs. In addition, from 8% to 50% of patients referred to PR never attended to it and around 10% to 32% of those who started a PR program dropped out at some point before completion¹⁵15. Keating A, Lee AL, Holland AE. Lack of perceived benefit and inadequate transport influence uptake and completion of pulmonary rehabilitation in people with chronic obstructive pulmonary disease: a qualitative study. J Physiother. 2011;57(3):183-90. doi: 10.1016/S1836-9553(11)70040-6
https://doi.org/10.1016/S1836-9553(11)70... .

The American Thoracic Society and European Respiratory Society agreed that, to improve the implementation, use and provision of PR, it is important to offer continuous education to the health professionals who will perform PR to the patients⁷7. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, et al. An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373-86. doi: 10.1164/rccm.201510-1966ST
https://doi.org/10.1164/rccm.201510-1966... . International studies have shown that the preparedness of health professionals and physical therapist to perform PR are low regarding knowledge, experience, and confidence in managing patients with CRD, especially in rural and remote areas¹⁶16. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. How prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? Aust J Rural Health. 2012;20(4):200-7. doi: 10.1111/j.1440-1584.2012.01288.x
https://doi.org/10.1111/j.1440-1584.2012... ^)-(1818. Chen YJ, Fan JY, Guo SE, Hwang SL, Yang TM. Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists. Int J Chron Obstruct Pulmon Dis. 2017;12:2695-702. doi: 10.2147/COPD.S142124
https://doi.org/10.2147/COPD.S142124... . In Brazil, there is a knowledge gap regarding health professionals’ ability to perform PR, as there are no published studies. This study is the first to evaluate the preparedness of health care practitioners in Brazil to perform PR to people with CRD. Thus, this study aimed to assess the knowledge, confidence, and clinical experience of health professionals to perform PR in the public health system in two cities in Minas Gerais State, Brazil.

METHODOLOGY

Study design

This survey is part of a larger project that intends to implement low-cost pulmonary rehabilitation in the Brazilian public health system. All participants provided written informed consent to participate.

Participants

Study participants were health care practitioners who worked predominantly in the primary and secondary levels of the public health system and received patients from all specialties, thus being considered generalists. The workshop was held at two cities in Minas Gerais (city A was 14 kilometers from the capital and city B was 239 kilometers) and all professionals who showed an interest in attending the training workshop were included. Participants who filled out the questionnaire but did not identify their professional category were excluded.

Procedures

This study is part of a larger project aimed at training health professionals to implement low-cost PR in Brazil, called Projeto Respirar - Pulmões Pela Vida [Breathe Project - Lungs for Life], from the Federal University of Minas Gerais. Two cities in the Minas Gerais State, Brazil, showed interest to participate in this project and implement low-cost PR in the public health system, since there were no local pulmonary rehabilitation programs. Municipal Health Departments were responsible for inviting health professionals to participate. Each city divided the training into two days, making the workshop available in the morning and afternoon, so as not to impact on health services. Health professionals could choose whether or not they would like to participate.

The first recruitment took place in April 2018, in one city, and the second recruitment in another city, in November 2018. All the health professionals who agreed to participate were informed in advance about the research project and filled out the consent form before the workshop. Data collection took place in the auditorium provided by the health departments, in person, moments before the workshop entitled “Pulmonary rehabilitation and the multiprofessional health team.” The health professionals (including physical therapists) who attended the workshop were then asked to complete the pre-workshop questionnaire. The questionnaire was anonymous.

Questionnaire

The questionnaire used in this study was designed by the Breathe Easy Walk Easy (BEWE) project, ⁽¹⁶16. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. How prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? Aust J Rural Health. 2012;20(4):200-7. doi: 10.1111/j.1440-1584.2012.01288.x
https://doi.org/10.1111/j.1440-1584.2012... and was translated into Portuguese and adapted for the Brazilian population.

The questionnaire evaluated health care practitioners’ experience, training, and confidence in managing people with CRD. However, COPD was the main condition used to evaluate the professionals’ knowledge due to its higher prevalence and the strong evidence of the benefits of PR in this patients.

The questionnaire included questions on demographics and prior knowledge, clinical experience, training, and confidence in managing people with CRD, particularly in performing PR. Participants’ knowledge was evaluated by 19 multiple-choice questions about a COPD case vignette. The response options were “true,”, “false,” or “unsure,” A score of 1 point was given for each correct answer and zero if the response was “unsure,” incorrect, or omitted. Participants’ prior experience and training in PR were self-rated via nine and eight questions, respectively, using 3-point Likert scales (1 to 3) with anchors of “none,” “a little,” and “a lot”, and confidence in performing PR was also self-rated in 10 questions using 4-point Likert scales (1 to 4) with anchors of “not at all,” “a little,” “moderately,” and “a lot”.

Sample Size

A sample calculation was performed for the multiprofessional team and another for the physical therapists. Calculations were based on the outcome “knowledge about PR.” For sample calculations, the total population of MT and PT professionals was considered, using data provided by the Municipal Health Departments. Adding up the number of professionals from the two cities, 7,200 professionals were part of the MT and 47 of the PT. Those were the numbers used for the calculation.

As the expected result is unknown, the chance of it being 50% positive and 50% negative was considered. Thus, the outcome “knowledge about PR” was considered to be 50%. A 5.5% error and a 90% confidence interval were considered. The calculation determined a sample size of 39 physical therapists and at least 217 other health care professionals. The website <openepi.com/SampleSize/SSPropor.htm>¹⁹19. Dean AG, Sullivan KM, Soe MM, Mir RA, editors. OpenEpi: Open Source Epidemiologic Statistics for Public Health [Internet]. [place unknown]; 2013 [cited Sept 17, 2021]. Available from: https://www.openepi.com/Menu/OE_Menu.htm
https://www.openepi.com/Menu/OE_Menu.htm... was used for sample calculation.

Data analysis

Descriptive continuous data are presented as mean and standard deviation (SD), or median and interquartile range, according to the sample distribution. Categorical variables are presented in absolute values and percentage. Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 25.0.

The participants were divided into two subgroups: physical therapists (PT) and multiprofessional team (MT) (all health care professional, but physical therapists). The data from the PT were analyzed separately from the data from the MT because as the former usually have the expertise to conduct exercise testing and training for people with CRD in a PR program.

RESULTS

Participant characteristics

Table 1 shows participant characteristics. A total of 300 professionals signed up to participate in the workshop, and, of these, 277 met the inclusion criteria and two were excluded for not having filled in the “profession” field on the form. The “others” category corresponds to oral health technicians (n=2), nurse technicians (n=62), and nursing auxiliaries (n=2). The participants’ workplaces were health centers, specialized clinics, or hospitals. The time since graduation was <5years for 19.1% (n=49) of the professionals, 5 to 10 years for 23.3% (n=60), and >10 years for 57.6% (n=148). The time in their current job position was <5 years for 36.8% (n=98) of the professionals, 5 to 10 years for 26.7% (n=71) of the professionals, and >10 years for 36.5% (n=97) of the professionals. Most participants were specialists in their areas of expertise (n=208) and had completed complementary training: 17.5% (n=48) professional development course; 45.5% (n=125) specialization; 8.4% (n=23) specialist residency; 2.5% (n=7) master’s degree; 1.1% (n=3) PhD degree, and 0.7% (n=2) post-doctoral training.

Knowledge

The mean total knowledge score (number of correct answers out of 19) was 10±3 for physical therapists and 6±3 for multiprofessional teams. The question with the highest rate of correct responses was “COPD means chronic obstructive pulmonary disease,” which was correctly chosen by all PT and 91% of health practitioners (Table 2). Questions relating to the disease pathophysiology and patient education showed higher rates of correct responses than those related to PR for all professionals. Physical therapists had few correct answers to questions related to the six-minute walk test (6MWT), such as the importance of the 6MWT, how to measure the distance on this test, how to prescribe exercise routines based on this test, and the minimum clinically important difference for COPD after PR, and about the purpose of the Borg Scale.

Training

Table 3 shows details of the respondents’ self-ratings of their prior training to perform PR programs. The PT responded to questions related to their clinical practice, whereas the other healthcare practitioners were evaluated on the more generic aspects of care. The results show that both PT and MT had none or low training to perform a PR program.

Experience

Table 4 shows details of the respondents’ self-rating of their experience to work in a PR program. The experience was also evaluated separately based on the physical therapists’ clinical practice and also on the more generic aspects of the care provided by the MT. As with training, experience was rated as none or low for both PT and MT.

Confidence

Table 5 presents the self-rated confidence to perform PR, separating physical therapists from MT. Few PT or MT reported “a lot” of confidence for any component evaluated.

DISCUSSION

The main findings of this study, related to the questionnaire topics, demonstrated that: i) Objectively measured knowledge was low for PT in the areas of 6MWT performance, how to prescribe exercises based on 6MWT results, as well as knowledge about the clinically important change in 6MWT distance during reassessment after a PR program. The knowledge of the MT group was low particularly regarding the pathophysiology of COPD; ii) Self-reported training showed that PT had little or no training to prescribe individualized exercise, or to plan and carry out a PR program, and that MT had little or no training to evaluate patients with CRD; iii) Self-reported experience showed that most PT had some experience with PR, but none with performing spirometry, and that MT had no experience in most items assessed, but reported having some experience in evaluating individuals with CRD; iv) Self-reported confidence showed that PT felt “a little confident” to perform PR programs, and the MT group felt “a little confident” to work on educational programs for people with CRD.

Knowledge, clinical experience, and confidence are key elements clinical practitioners must have to manage individuals with CRD and conduct the multiple components of PR programs, such as patient assessment, exercise prescription and physical training, patient self-care education, nutritional advice and psychosocial support, among others. Pulmonary rehabilitation performed by a multiprofessional team with expertise and experience in the area can bring significant benefits to patients with CRD²⁰20. Clini E, Holland A, Pitta F, Troosters T. Textbook of Pulmonary Rehabilitation. Amsterdam: Springer International Publishing; 2018. doi: 10.1007/978-3-319-65888-9
https://doi.org/10.1007/978-3-319-65888-... . Physical therapists are accredited to provide exercise rehabilitation²¹21. Garrod R, Lasserson T. Role of physiotherapy in the management of chronic lung diseases: An overview of systematic reviews. Respir Med. 2007;101(12):2429-36. doi: 10.1016/j.rmed.2007.06.007
https://doi.org/10.1016/j.rmed.2007.06.0... ^),(2222. Johnston CL, Maxwell LJ, Alison JA. Pulmonary rehabilitation in Australia: A national survey. Physiotherapy. 2011;97(4):284-90. doi: 10.1016/j.physio.2010.12.001
https://doi.org/10.1016/j.physio.2010.12... . For this reason, PT and MT groups are reported separately as their roles within a PR program are different, with the PT providing exercise prescription and training with some patient self-management education and the MT providing education within their discipline-specific expertise related to CRD.

In a PR program, a comprehensive patient assessment is essential to identify and treat the systemic manifestations of CRD, such as dyspnea, peripheral muscle dysfunction, reduced exercise tolerance, anxiety, and depression²⁰20. Clini E, Holland A, Pitta F, Troosters T. Textbook of Pulmonary Rehabilitation. Amsterdam: Springer International Publishing; 2018. doi: 10.1007/978-3-319-65888-9
https://doi.org/10.1007/978-3-319-65888-... ^),(2323. Kocks JWH, Asijee GM, Tsiligianni IG, Kerstjens HAM, van der Molen T. Functional status measurement in COPD: a review of available methods and their feasibility in primary care. Prim Care Respir J. 2011;20(3):269-75. doi: 10.4104/pcrj.2011.00031
https://doi.org/10.4104/pcrj.2011.00031... . Assessment guides treatment objectives to achieve goals according to patients’ individual needs²⁰20. Clini E, Holland A, Pitta F, Troosters T. Textbook of Pulmonary Rehabilitation. Amsterdam: Springer International Publishing; 2018. doi: 10.1007/978-3-319-65888-9
https://doi.org/10.1007/978-3-319-65888-... ^),(2222. Johnston CL, Maxwell LJ, Alison JA. Pulmonary rehabilitation in Australia: A national survey. Physiotherapy. 2011;97(4):284-90. doi: 10.1016/j.physio.2010.12.001
https://doi.org/10.1016/j.physio.2010.12... .

In this study, both PT and MT groups demonstrated very little knowledge, experience, or confidence to carry out the assessment of individuals with CRD. Many PT reported having limited ability to perform the 6MWT, and many MTs reported lacking the experience and confidence to assess individuals with CRD. In addition, both groups had difficulty understanding the use of body mass index for nutritional assessment, or how to assess health-related quality of life, patient treatment goals, or to perform and interpret the spirometry test. These issues must be improved in both groups since patient assessment and reassessment are essential to measure changes in patient outcomes and to ensure the quality of PR services²⁴24. Yawn BP, Mintz ML, Doherty DE. GOLD in Practice : Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting. Int J Chron Obstruct Pulmon Dis. 2021;16:289-99. doi: 10.2147/COPD.S222664
https://doi.org/10.2147/COPD.S222664... .

Another point that stands out in this study is the low number of correct answers in the objective assessment of the COPD case vignette (PT=10±3 vs MT=6± 3). This result shows the lack of knowledge of both PT and MT about COPD, which is one of the most prevalent CRD, as well as the low level of knowledge in assessing functional exercise capacity, health-related quality of life, prescribing exercises, and assessing patient outcomes at the end of a PR program. These elements of PR are essential for providing rehabilitation and managing patients with CRD. Moreover, the health professionals reported that they had received insufficient training and had little experience in PR, which impacted the answers about confidence levels, as very few PT and MT reported having “a lot” of confidence to carry out the PR.

A survey carried out to assess the skills of health practitioners to perform PR in rural and remote areas in Australia found that experience levels and previous training were low in topics such as assessing people with COPD, performing the 6MWT and spirometry, prescribing individualized exercise, and carrying out the PR program. Furthermore, few health practitioners reported being very confident in differentiating COPD and bronchiectasis, prescribing an exercise program, or monitoring the results of a PR program¹⁶16. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. How prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? Aust J Rural Health. 2012;20(4):200-7. doi: 10.1111/j.1440-1584.2012.01288.x
https://doi.org/10.1111/j.1440-1584.2012... . The total mean knowledge score of the Australian study¹⁶16. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. How prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? Aust J Rural Health. 2012;20(4):200-7. doi: 10.1111/j.1440-1584.2012.01288.x
https://doi.org/10.1111/j.1440-1584.2012... was 8.5 (SD 4.5) correct answers out of 19 questions. The methodology used in the current study was similar to that one¹⁶16. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. How prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? Aust J Rural Health. 2012;20(4):200-7. doi: 10.1111/j.1440-1584.2012.01288.x
https://doi.org/10.1111/j.1440-1584.2012... , which allows the results to be compared. Generally, the findings of both studies indicate a lack of skills on the part of health practitioners and indicate that training should be improved not only for patient assessment and exercise prescription and training, but also for background knowledge, such as the pathophysiology of CRD.

One of the physical therapist’s requirements is to assess functional exercise capacity, as it is the basis for prescribing the intensity of exercise training during a PR program²³23. Kocks JWH, Asijee GM, Tsiligianni IG, Kerstjens HAM, van der Molen T. Functional status measurement in COPD: a review of available methods and their feasibility in primary care. Prim Care Respir J. 2011;20(3):269-75. doi: 10.4104/pcrj.2011.00031
https://doi.org/10.4104/pcrj.2011.00031... ^),(2525. Zainuldin R, Mackey MG, Alison JA. Prescription of walking exercise intensity from the 6-minute walk test in people with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 2015;35(1):65-9. doi: 10.1097/HCR.0000000000000074
https://doi.org/10.1097/HCR.000000000000... . The 6MWT²⁵25. Zainuldin R, Mackey MG, Alison JA. Prescription of walking exercise intensity from the 6-minute walk test in people with chronic obstructive pulmonary disease. J Cardiopulm Rehabil Prev. 2015;35(1):65-9. doi: 10.1097/HCR.0000000000000074
https://doi.org/10.1097/HCR.000000000000... is the most widely used test to assess functional exercise capacity and requires few resources²⁶26. Huang LH, Chen YJ. The 6-minute walk test to assess exercise capacity of patients with chronic obstructive pulmonary disease. Eur Respir J. 2016;48(suppl 60). doi: 10.1183/13993003
https://doi.org/10.1183/13993003... . Physical therapists are the most qualified and accredited health professionals to carry out the exercise assessment and prescription¹⁸18. Chen YJ, Fan JY, Guo SE, Hwang SL, Yang TM. Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists. Int J Chron Obstruct Pulmon Dis. 2017;12:2695-702. doi: 10.2147/COPD.S142124
https://doi.org/10.2147/COPD.S142124... ^),(2222. Johnston CL, Maxwell LJ, Alison JA. Pulmonary rehabilitation in Australia: A national survey. Physiotherapy. 2011;97(4):284-90. doi: 10.1016/j.physio.2010.12.001
https://doi.org/10.1016/j.physio.2010.12... ^),(2727. Summers RH, Ballinger C, Nikoletou D, Garrod R, Bruton A, Leontowitsch M. Giving hope, ticking boxes or securing services? A qualitative study of respiratory physiotherapists' views on goal-setting with people with chronic obstructive pulmonary disease. Clin Rehabil. 2017;31(7):978-91. doi: 10.1177/0269215516658937
https://doi.org/10.1177/0269215516658937... . However, in this study, physical therapists had low knowledge scores related to the 6MWT, such as measuring the covered distance, the importance of two tests (learning effect), prescribing exercises based on test results, and the minimum clinically important improvement in the 6MWT after PR. In addition, the amount of self-reported training to perform the 6MWT was low and most reported low confidence in performing it. This is concerning, as the 6MWT is considered a standard test for assessing patients’ functional exercise capacity.

In a cross-sectional study¹⁸18. Chen YJ, Fan JY, Guo SE, Hwang SL, Yang TM. Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists. Int J Chron Obstruct Pulmon Dis. 2017;12:2695-702. doi: 10.2147/COPD.S142124
https://doi.org/10.2147/COPD.S142124... with 379 respiratory therapists who answered a self-administered questionnaire, the authors were able to verify the professionals’ opinions about PR programs and how these opinions influenced their behavioral intentions to promote the PR program. The study concluded that positive attitudes, support from managers and co-workers, and self-efficacy needed to be improved. Thus, they suggested that hospital managers should establish guidelines related to the functions of respiratory therapists in PR, providing greater professional support, as well as enabling a supportive environment with more time available for initial contact with the patient to explain the benefits of PR. The authors also suggested the need to provide opportunities for continuing education and communication training. The participation of health practitioners in continuing education (in-service) and training programs, aimed at developing skills for carrying out PR, would help establish effective programs in different settings and could directly influence the provision of PR and increase the accessibility and acceptance of PR by patients¹⁸18. Chen YJ, Fan JY, Guo SE, Hwang SL, Yang TM. Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists. Int J Chron Obstruct Pulmon Dis. 2017;12:2695-702. doi: 10.2147/COPD.S142124
https://doi.org/10.2147/COPD.S142124... ^),(2828. Ke X, Marvel J, Yu TC, Wertz D, Geremakis C, et al. Impact of lung function on exacerbations, health care utilization, and costs among patients with COPD. Int J Chron Obstruct Pulmon Dis. 2016;11(1):1689-703. doi: 10.2147/COPD.S108967
https://doi.org/10.2147/COPD.S108967... ^)-(3030. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. Does delivery of a training program for healthcare professionals increase access to pulmonary rehabilitation and improve outcomes for people with chronic lung disease in rural and remote Australia? Aust Heal Rev. 2014;38(4):387-95. doi: 10.1071/AH14009
https://doi.org/10.1071/AH14009... .

Several studies have shown the diversity of health care practitioners that may be responsible for performing PR programs, as well as the differences between programs regarding what is included in assessment, interventions, and monitoring¹⁶16. Johnston CL, Maxwell LJ, Maguire GP, Alison JA. How prepared are rural and remote health care practitioners to provide evidence-based management for people with chronic lung disease? Aust J Rural Health. 2012;20(4):200-7. doi: 10.1111/j.1440-1584.2012.01288.x
https://doi.org/10.1111/j.1440-1584.2012... ^),(1818. Chen YJ, Fan JY, Guo SE, Hwang SL, Yang TM. Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists. Int J Chron Obstruct Pulmon Dis. 2017;12:2695-702. doi: 10.2147/COPD.S142124
https://doi.org/10.2147/COPD.S142124... ^),(3131. Janssens W, Corhay JL, Bogaerts P, et al. How resources determine pulmonary rehabilitation programs: A survey among Belgian chest physicians. Chron Respir Dis. 2018;16. doi: 10.1177/1479972318767732
https://doi.org/10.1177/1479972318767732... . Due to the diversity, it is important that each health care practitioner knows their role and scope of practice in promoting and providing PR. The results of this study showed that only 6.5% of the MT group reported having the confidence to determine which patients could be referred to PR, showing a lack of knowledge about CRD relevant to PR referral.

One of the possible reasons why our study found low rates of knowledge, experience, and confidence of PT and MT groups to carry out PR may be related to the professional skills among participants. Most participants were general practitioners, as they were from primary health care, where they deal with a diversity of patient cases. Regardless of the training of these health professionals, there was a knowledge gap regarding the management of CRD, the benefits of PR, and the referral of patients to PR, which indicated a lack of continuing education. Therefore, continuing education is essential to improve the quality of care for people with CRD²⁰20. Clini E, Holland A, Pitta F, Troosters T. Textbook of Pulmonary Rehabilitation. Amsterdam: Springer International Publishing; 2018. doi: 10.1007/978-3-319-65888-9
https://doi.org/10.1007/978-3-319-65888-... .

The lack of skills among professionals to manage people with CRD and to carry out PR can be considered a barrier to creating new PR services⁷7. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, et al. An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med. 2015;192(11):1373-86. doi: 10.1164/rccm.201510-1966ST
https://doi.org/10.1164/rccm.201510-1966... ^),(1414. Johnston KN, Young M, Grimmer KA, Antic R, Frith PA. Barriers to, and facilitators for referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners : a qualitative study. Prim Care Respir J. 2013;22(3):319-24. doi: 10.4104/pcrj.2013.00062
https://doi.org/10.4104/pcrj.2013.00062... ^),(3232. Johnston CL, Maxwell LJ, Alison JA. Establishing and delivering pulmonary rehabilitation in rural and remote settings: The opinions, attitudes and concerns of health care professionals. Aust J Rural Health. 2015;24(2):106-14. doi: 10.1111/ajr.12202
https://doi.org/10.1111/ajr.12202... . The multidisciplinary team lack of knowledge about the pathophysiology of the main respiratory diseases and the components of PR may hinder the identification of candidates for the programs and directly influence referral rates.

This study presents some limitations. It was not possible to differentiate the workplaces of health professionals (primary care, clinics, and hospitals), as the questionnaire did not include this specification, but the municipal health departments reported that the participants were predominantly enrolled in primary and secondary levels of care. Furthermore, it was not possible to distinguish which professionals did or did not work with CRD patients; however, all professionals should have been able to answer questions about CRD and PR.

Another point to be clarified concerns the presentation of the results separating the two cities. In the subgroup analysis, the MT and PT groups from cities A and B were compared in relation to the topics of the variable’s knowledge, experience, training, and confidence. As the groups presented similar results between the cities, with no significant difference, it was decided to present the results of this study in a unified way, as we believe that this would not impact the study and would facilitate understanding.

Another analysis was performed regarding knowledge (number of correct answers in the clinical case) of each of the professions that compose the MT group. The professions that had the highest number of correct answers in the clinical case were physicians, with a mean of 8.2±2 vs 10.6±2; physical education professionals, with a mean of 9±3 vs 9±1; and nurses, with a mean of 6±2 vs 7±3, in cities A and B, respectively. These findings are consistent with a study in low- and middle-income countries, which points to the lack of knowledge of health professionals, including physicians, who are considered to be primarily responsible for most referrals of CRD patients to PR, as a barrier to the implementation of these programs³³33. Bickton FM, Shannon H. Barriers and Enablers to Pulmonary Rehabilitation in Low-and Middle-Income Countries: A Qualitative Study of Healthcare Professionals. Int J Chron Obstruct Pulman Dis. 2022;17:141-53. doi: 10.2147/COPD.S348663.
https://doi.org/10.2147/COPD.S348663... .

This is a pioneering study in Brazil, which evaluated public service health professionals in two cities in Minas Gerais, therefore, the findings can be generalized in light of the recruitment process of the participants. Therefore, future studies should evaluate the preparedness of health professionals to manage patients with CRD and perform PR more comprehensively, including the different regions of Brazil.

The study raises some questions for reflection and further investigation, for example: Does professional training at undergraduate level or at professional training courses give the necessary skills for pulmonary rehabilitation? Do health practitioners really know their roles when working in pulmonary rehabilitation? What is the impact of a training program for health practitioners on the performance pulmonary rehabilitation? These results could help managers create public policies to train and equip health professionals to provide comprehensive care for this population.

CONCLUSION

Both PT and MT groups had low levels of knowledge, training, clinical experience, and confidence to carry out or contribute to PR programs. The PT showed a lack of knowledge on issues specific to their own practice, such as how to perform the 6MWT and prescribe exercise training programs. The MT demonstrated a lack of generic skills, such as managing CRD patients, and planning and carrying out patient education programs. Therefore, it is necessary to develop training and continuing education programs for these health professionals, according to their professional area, so that the appropriate management of people with CRD can be enabled, especially the referral to and provision of sustainable PR programs.

ACKNOWLEDGEMENTS

To the health professionals who took part in the project, to physical therapist Heloisa Nascimento Silva, for her support in data collection, to scientific initiation scholarship holders Tayna Amaral, Letícia Fernandes, and Alessia Aguiar, for their dedication in data tabulation, to the Brazilian Hospital Services Company (EBSERH), for releasing the researcher to temporarily dedicate herself to scientific writing.

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