An Innovative Approach to Fight Asthma in Children
Thammasat University Hospital and National Science and Technology Development Agency

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Asthma is a chronic disease of the respiratory tract that is common in all age groups from young children to seniors. The World Health Organization (WHO) estimates that approximately 15 million people are affected by asthma per year and that there are 250,000 asthma deaths annually. Therefore, Asthma is major global health challenge. The increasing asthma prevalence in the Asia Pacific region is linked to increasing air pollution. The prevalence of childhood asthma in Asia is currently around 10-15% and was more than 10 years ago. In Thailand, some 1.4 million children suffer from asthma, especially children under 5 years old, the group unable to use inhalator devices. Thus, they suffer greater asthma exacerbations, 100,000 patients per year, and seek treatment in emergency rooms, 400,000 patients per year. These lead to reduced quality of life, cause children to miss school and an adverse economic impact on families through missing work and travel and medical costs. The mean total, direct and indirect cost per sick child in 2013 was 8,009, 6,723 and 1,285 Baht (USD 258, 216, 41), respectively. This translates into an economic burden of asthmatic children for Thailand of 10,972 million Baht (USD 354 million). Moreover, asthma causes more than 1,000 deaths per year. One key reason for frequent hospital admissions and death is poor asthma control in the community because of children cannot use currently available inhalers; this means little or no medicine gets into the lungs. The most commonly used drug delivery system for asthmatics is the pressurized metered-dose inhaler (pMDI) which delivers drugs to the diseased lung where they act rapidly. However, for optimal effect, it requires good hand mouth lung coordination which is lacking in young children and older individuals. Therefore, an add-on device called a spacer is used overcome the pMDI limitations. Indeed, the spacer increases lung drug deposition by 30%. However, these devices are mostly imported and cost up to USD30-40 which is not reimbursable by the Thai health system. Based on survey, only 10% of child patients use spacers. They are exclusively used in hospitals in the larger cities and are unavailable to patients in rural areas. Furthermore, we have also found that medical staff are not only unable to teach the pMDI inhaler technique properly but they are also unaware of the usefulness of spacers. Our team has invented a Do-It-Yourself (DIY) spacer using readily available materials such as plastic bottles to make this inexpensive device accessible to all patients. We have also initiated a network of volunteers to disseminate knowledge of how to make these DIY spacers so that patients around the country can afford to use them, control asthma better and, hopefully, save lives.

B. Strategic Approach

 2. What was the solution?
We will: (i) engage asthma suffers and their families to produce their own DIY spacer from recycled water bottles, (ii) promote its use through education, materials and online resources, and (iii) bring together asthma affected families and health care workers, including village workers, in an asthma network.

 3. How did the initiative solve the problem and improve people’s lives?
Our project improved the lives of asthma sufferers and their families by adopting four key strategies, described below. First of all, there was need for a spacer that was cheap, able to use the pMDI, and user friendly by younger children, in particular. The ability to use the spacer properly and therefore effectively is absolutely critical in good asthma control. Given these parameters, a team was set up comprising medical staff from the asthma clinic at Thammasat University and biomedical engineers from the National Metal and Materials Technology Center (MTEC). The result of this collaboration was the design of a Do-It-Yourself (DIY) spacer based on recycled water bottles. These are readily available, made of good quality plastic resulting in a reasonably robust spacer that costs about 2 US dollar. By contrast, an imported spacer costs 30-40 USD. Therefore, this was a sustainable, cheap and easily accessible solution to our paediatric asthma challenge. We do not have a restrictive patent on this spacer so this will allow companies to produce variations on the basic design i.e. this is an “open platform” spacer. Using this strategy allows for the scaling up of production because companies have the necessary infrastructure and therefore greater dissemination and accessibility of the spacer. Moreover, companies are proud to be associated with this innovation and to promote its uptake. To date, about 100,000 spacers have been produced. In order to promote the proper use of the DIY spacer, we have instituted a “Training the Trainers” strategy to show how the spacer can be produced at home. This has taken the form of trainers going out into the community, including more remote communities, to train group of volunteers who consist of parents of asthma sufferers and medical staff, including village health workers. When trained, these volunteers then train people in their own communities. This allows for knowledge to be disseminated in an exponential fashion. In addition, valuable feedback from the volunteers is useful to fine tune the design of the spacer. We promote education through our Asthma Network as a cornerstone piece of our overall strategy. Knowledge of asthma, its causes, how to manage it at home and when to seek medical help are key elements that we teach. Furthermore, we have developed educational packages that can be accessed online via our own webpage, YouTube, Facebook, and free iOS and Android App. So far we have seen a decline in asthma admissions and an improved quality of life for children and parents. Anecdotally, the feedback we are getting via our network is positive.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
This initiative is both creative and innovative because we brought together health care professionals and biomedical engineers to design a new DIY spacer that has empowered parents to be more actively involved in the care of their asthmatic children. We focus on the poorest children who cannot afford a commercial spacer. Moreover, we have created in parallel an Asthma Network that extends to remote areas and brings together health staff, patients, their carers and volunteers to share knowledge, experience and provide support for the most vulnerable asthma patients. This DIY spacer is being used across Thailand and has received worldwide recognition and awards from Switzerland, Korea, Taiwan, and Thailand. These awards are testament to the innovative nature of our invention.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative was implemented by the Thammasat Asthma care team and the biomedical engineers from MTEC through our Asthma Network. There are at least 120,000 asthmatic children who have benefited from this initiation. Some 20,000 asthmatic children are now receiving quality health care and education from 136 Asthma Network hospitals across Thailand. Approximately 10,000 asthmatic children have received the new DIY spacer under the Siam Cement Group Public Company Limited (SCG) Chemicals project in which they pulled all their resources for making DIY spacer, called “One Child, One Spacer” project and so has allowed vulnerable children to have their first spacer. Untold numbers of parents and medical staff have viewed our materials online on YouTube (more than 5,000 hits) and Facebook (more than 1,000 Likes) as well as newspaper articles and television broadcasts on spacer assembly and asthma care.
 6. How was the strategy implemented and what resources were mobilized?
Our strategy to fight paediatric asthma was implemented using a multipronged approach. Firstly, we set up the Asthma Network which was a network of volunteers from paediatric asthma clinics in rural and urban hospitals, patients and their parents, and other stakeholders. This network did not require funds to set up and relied solely on people donating their time without strings attached. We identified children who were unable to use their pMDI or did not have one. These children were given the new DIY spacer and their parents told how to use it. Secondly, we adopted an energetic programme of education and training through our “Train the Trainer” programme which also provides an opportunity to distribute the DIY spacer. We made the full use of social media (Facebook and YouTube) and developed an “App” on Asthma that is downloadable for free. No financial resources were required to develop these apps. Thirdly, we established good relations with plastic manufacturers (SCG Chemicals) and the Plastics Institute of Thailand (Ministry of Industry) emphasising the need to adopt a social marketing attitude and produce their form of spacer cheaply. This message resounded well because these institutions have corporate social responsibility (CSR) programmes. Because of our policy of providing the DIY knowhow for free and the knowledge that there is unmet medical need (i.e. market), no major investment of funds was needed to set up production. Our engaging with manufacturers had a positive effect in that they felt proud to be associated with the DIY spacer project.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
Several stakeholders have been involved in this project. The Asthma patient organisation at Thammasat University hospital (TU Asthma Club) which is made up of health staff and patients initiated the DIY spacer project to encourage volunteers to join hands to help produce the DIY spacer and distribute it to patients whose asthma was poorly controlled. The Asthma Club is strong and has an active membership of more than 200 patients. It represented Thailand at the Inaugural Asia Pacific Lung Health Summit: A Patient’s Perspective where asthma and chronic lung disease patients presented the DIY spacer and other projects. The DIY spacer project was well received and there was interest to expand the network in the region. There are several other stakeholders. The National Metal and Materials Technology Center (MTEC) which coinvented the DIY spacer and produced scientific and economic data to support the project. The asthma foundation is the main organization who creating knowledge sharing for health care professionals by the annual meeting. The Asthma Foundation is the main organisation in Thailand for exchanging knowledge between health care professionals. The National Health Service Organisation (NHSO) which set up the “Easy Asthma Clinic” programme collects data on asthma treatment and spacer use and makes these data available on the Easy Asthma Clinic website and Facebook. The Plastic Institute of Thailand co-developed another version of spacer called the “Thai Kid’s” spacer with Thammasat Asthma club and is able to mass produce them. SCG Chemicals also produced a variation on the DIY spacer and has been involved in its distribution, especially in rural areas, through a network of volunteers.

 8. What were the most successful outputs and why was the initiative effective?
There have been a number of highly successful outputs. We have distributed about 100,000 DIY spacers since the start of the project in 2010. These numbers are testament to the enthusiastic engagement of our volunteer networks and the manufacturers who have proudly engaged in this project. We have set up a functioning networking with members from the both public and private sector. It is a forum for sharing ideas and innovative approaches to treating asthma as well as conducting training. The network has now expanded to 134 hospitals in 56 provinces. Another significant output is the increased knowledge and awareness of the severity of asthma and its recognition, how to make the DIY spacer, and the free availability of the Asthma Care App that can be downloaded. This has allowed the most vulnerable asthmatics to have a better handle of their disease and management at no cost. Finally, since the start of the project seven years ago, we estimate that Thailand’s import bill for foreign produced spacers has declined by some 150 million Thai baht (USD 4.5m).

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles were cultural. The health care workers did not like the DIY spacer because it looked “cheap and cheerful”, it had not been produced by a big name foreign company and so they think that it would be ineffective. There is a strong feeling that quality and expensive imported goods are superior to the locally produced ones and so a priori confidence is greater for the imported product. Therefore, we set out to show the effectiveness of our DIY spacer by show casing it at international level. Worldwide recognition has been gained in the form of awards at the Geneva International Invention Fair, and at the Seoul International Invention Fair (SIIF) by Taiwan and Korea. We also received awards from the National Research Council of Thailand and the Office of the Public Sector Development Commission (Outstanding National Public Service Award). These gave our DIY spacer great credibility. Moreover, we assessed formally the efficacy of the spacer. The first study compared the efficacy and compliance between the DIY spacer and a commonly used imported spacer. The results showed that the DIY spacer was comparably effective in controlling asthma and that patients liked it. The second study compared the response of bronchodilator treatment of the DIY spacer vs. nebulized treatment during mild to moderate asthma attacks in children. Efficacy was similar but nebulisation was associated with more adverse effects – tachycardia and agitation – and less patient satisfaction.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Our programme included rural hospitals in many parts of Thailand, including the border provinces where the health system is less well represented. These hospitals do not have paediatricians with expertise in asthma and referrals to specialist centres is problematic because of the long distances involved. Consequently, only some 10 percent of asthmatic children receive good treatment with a spacer. After the train the trainer programme and the DIY spacer project, these hospitals are now able to manage asthma with confidence and develop into mini specialist centres with outreach networks to serve their local communities. Furthermore, we have a long distance programme of continuing professional development which is conducted by teleconferences and the mobile phone asthma app. Currently, there are more than 100,000 asthmatic children who use the DIY spacer and receive better treatment. The rates of emergency room visits and hospital admissions for asthma are much reduced following our project. Other benefits include more children able to send more time at school and play with their friends. We have expanded our training programme and DIY spacer project to Myanmar, a country with a low per capita income, high asthma prevalence and limited resources for optimal asthma management. The government in Myanmar only supports anti-asthma medications but not medical devices; thus, the majority of poor families cannot pay for spacers. We have established links with and trained staff at the Yangon Children’s and Magway Region General hospitals and created networks to make and distribute the DIY spacers and empower local communities to manage asthma better. We are hoping to take this initiative into rural Myanmar and consolidate the good relationship that exists between us and our Myanmar colleagues.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Yes. Closer relationship between the hospital and patients has empowered not only the patients to engage more with the staff but has also increased awareness of accountability and openness amongst the staff. This also encourages our staff to advocate creatively for better treatment, more equipment and services for asthma patients in urban and rural areas.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Yes. This initiative benefits mostly poor rural populations, the most vulnerable in Thailand. We have also reached out to orphans by training their carers. We have outreach teams that visit communities to ensure that everyone has a chance to learn about asthma care; the main carer is most often the mother so training has necessarily to take this gender bias into account. Empowering mothers has a general positive knock on effect on the way they bring up happy children. Therefore, we have targeted the most vulnerable groups who are very often forgotten about.

Contact Information

Institution Name:   Thammasat University Hospital and National Science and Technology Development Agency
Institution Type:   Public Agency  
Contact Person:   Danu Prommin
Title:   Researcher in Biomedical Engineering  
Telephone/ Fax:   +(66) 2 564 6500 Ext. 74624/ +(66) 2 564 6501-5
Institution's / Project's Website:  
Address:   114 Thailand Science Park (TSP), Phahonyothin Road, Khlong Nueng, Khlong Luang
Postal Code:   12120
City:   Klong luang
State/Province:   Pathum Thani

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