1. By Alyssa Bessent University of Kansas - School of Nursing
Breathless in India
By Alyssa Bessent
University of Kansas - School of Nursing

2. Objectives
Knowledge: Discover the causes and interventions at the individual, community, and system level that have an impact on the level of chronic obstructive pulmonary disease (COPD) in India.
Skills: Asses and understand the social determinants in India and how they impact the differences in healthcare as compared to the United States.
Attitude: Broaden cultural competency to effectively work with individuals from India to improve health outcomes for all.

3. Life in India
India is a country in Southern Asia that host 1.34 billion people, the second most populated country in the world.
Hinduism, Islam, and Christianity are the top three religions.
It is a patriarchal society that values family, community, and tradition.
While these were common themes, India is such a large populous country that there a subtle culture shifts depending on where you visit.

4. Travels Abroad
Vellore
Vellore, Tamil Nadu is located in Southern India at coordinates ° N, ° E. It is approximately sq km and has a population of 3,936,311 according to the 2011 census (About, n.d.)
Map:

5. Christian Medical College
4-week observationship at Christian Medical College (CMC) in Vellore, Tamil Nadu in Southern India.
CMC was founded by Dr. Ida Scudder, a United States citizen, in 1900 and has become one of the top hospitals in India.
The majority of time was spent within the College of Nursing Community Health working with local nurses and students in Perumugai Village.

6. India and Chronic Obstructive Pulmonary Disease
COPD is the second leading cause of death in India, 11% (CDC, n.d.).
There are approximately 30 million COPD patients (Kohl, 2013).
Pic 1:
Pic 2:

7. The Possible Culprits
Possible causes or exacerbations of COPD in India include:
Smoking, especially with non-conventional forms of tobacco including hookah, bidi, or chillum
Exposure to biomass fuels like crop residues or woods or animal waste
70% of homes use biomass fuel for cooking and heating in poorly ventilated kitchens
Mosquito Coils (Koul, 2013)
**maybe include the other possible causes listed in the article, air pollution, genetics, etc.**
Bidi -
Biomass -

8. Current Interventions - Individual Level
Due to the large population, quite often interventions in India are targeted at prevention instead treatment. Below are interventions aimed at common causes of COPD that can be found in India.
Smoking: One study found 16% of individuals quit smoking after receiving advice to do so from the physician and 21% quit smoking after being informed by a non- doctor healthcare professional (Thankappan, 2014).
Biomass: In Perumugai Village, Community Health Nurses promoted current recommendation of using a propane stove or cooking outside instead of burning biomass indoors (Kalagouda Mahisale, 2016).

9. Current Interventions - Community Level
Smoking: Quit Tobacco International has created a program in India in which tobacco cessation methods are covered in undergraduate medical studies to prompt future physicians to advise against smoking (Thankappan, 2014). mCessation Programme is a program offered through the national government in which mobile phone user can sign up to receive tips about quitting (WHO, n.d.).
Biomass: There is currently no known intervention at the community or national level that targets the use of biomass fuel. This is likely due to the large percentage of the population that is under educated and cannot afford an alternative fuel source.

10. Current Interventions - System Level
Smoking: A number of laws have been passed in India to deter smoking.
Banning smoking in public place, worksites, and government buildings.
Banning the advertisement of tobacco products through mass media.
Enforcing graphic health label warning that cover 85% of both the front and back panel of the packaging (India, 2017)
Biomass and Mosquito Coils: Both of these possible causes have limited to no interventions.

11. Considerations for the Future
Difficulties in Preventing or Treating COPD:
Rural areas sometimes do not have access to spirometers or individuals qualified to conduct testing (Koul, 2013) so COPD remains undiagnosed. As for burning biomass, it is typically those in poverty that use this practice and there is not yet an equally affordable alternative. Mosquito coils have been found to increase indoor pollution (Liu, 2003) but there is not yet enough research on the dangers to humans to prevent this practice.
Recommendations for Nurses:
Advocate for a national campaign that address the dangers of cooking with biomass fuel.
Research the necessary steps to make propane and stoves available to those with limited income in the nurses area of influence.
Encourage and/or led studies that look at household air pollution and its correlation to the rise of non-communicable diseases.

12. My Most Profound Clinical Experiences
The geriatric club - A CMC initiative to improve the quality of life for elders.
The establishment of CMC Vellore nursing care in a new village.

13. My Most Profound Cultural Experience
Religious tolerance and welcoming smiles
Flowers in Hair:
Tolerance:

14. References
About Vellore | The Official website of Vellore District, Government of Tamil Nadu. (n.d.). Retrieved March 1, 2018, from
CDC Global Health - India. (n.d.). Retrieved March 1, 2018, from
India Details - Tobacco Control Laws. (2017.). Retrieved March 1, 2018, from
Kalagouda Mahishale, V., Angadi, N., Metgudmath, V., Lolly, M., Eti, A., & Khan, S. (2016). The prevalence of chronic obstructive pulmonary disease and the determinants of underdiagnosis in women exposed to biomass fuel in India- a cross section study. Chonnam Medical Journal, 52(2), 117–122.
Koul, P. (2013) Chronic obstructive pulmonary disease:Indian guidelines and the road ahead. Lung India 30(3). Doi: /
Liu, W., Zhang, J., Hashim, J. H., Jalaludin, J., Hashim, Z., & Goldstein, B. D. (2003). Mosquito coil emissions and health implications. Environmental Health Perspectives, 111(12), 1454–1460.
Thankappan, K. R. (2014). Tobacco cessation in India: A priority health intervention. The Indian Journal of Medical Research, 139(4), 484–486.
World Health Organization (n.d.), The missing O: Scaling up tobacco cessation in India using mobile technology. Retrieved March 1, 2018, from