Evaluation of guideline based management, implementation status and challenges in the implementation of SWAAS (Step wise approach to airway syndromes programme in Family Health Centers) - a comparison with the existing care for COPD and Asthma in Primary Health Centers was conducted to compare the treatment plan and characteristics of patients with obstructive airway diseases in a Family Health Centre (FHC) to those in a primary health centre (PHC) which is not a family health center in Thiruvananthapuram district, Kerala. The study also  assessed  the implementation status of the SWAAS program in the Family Health Centers (FHC) in Thiruvananthapuram district, Kerala and also determined the challenges in the implementation of the SWAAS program. The study was conducted in Family health center and Primary health centers using a mixed method from October 2018  to February 2019.The data was collected using a semi-structured questionnaire, IDI guide and FGD guide. Clearance from Institutional Ethics Committee in Health Action by People (HAP) and permission from the Directorate of Health Services was obtained.

The median duration of respiratory symptoms and history of self reported allergy was higher in the patients attending the Family Health Centers (FHCs), a reflection of the health seeking behavior due to better facilities at the FHCs. The exposure to dust and smoke was present in a significant number of study subjects in both the groups. There was no difference in the hospital visits or emergency department visits between the two groups. But there was a statistically significant difference in the average number of visits per patient to health center for taking injectable drugs and visits for nebulization. Guideline appropriate management was present in 44 patients from FHC and 10 patients from PHC. A higher number of patients in FHCs were managed as per standard guidelines than in the PHCs, which was statistically significant. On exploring the services offered by the SWAAS clinic, it was noticed that the attendance to smoking cessation classes were low. On assessing the implantation status, it was seen that monthly reports were being sent from all the FHCs, but the updating of registers were incomplete in 4 out of the 15 FHCs. It was also noticed that essential equipments like mini spirometer and nebulizer were non functional in one of the FHCs. 
In depth interviews revealed that the COPD control programme was essential in Kerala due to the high morbidity pattern of COPD and Asthma, previous irrational treatment modalities, high out of pocket expenditure, inaccessibility of services and absence of a specific protocol demanded a new programme to be established in the system.

Recommendations from the study.
  • Strengthening supervision of the functioning of the SWAAS clinic including the reporting and documentation.
  • Prescription auditing has to be performed to ensure guideline based management.
  • Timely replacement and maintenance of the essential equipment 
  • Services to be expanded to provide both pharmacological and non pharmacological management under Smoking cessation clinics under SWAAS.
  • Improving the infrastructure and other facilities at the Family Health center for conducting SWAAS clinic.
  • Extension of SWAAS clinic timings to afternoon also for detailed screening, counselling and monitoring. 
  • Recommendation for ongoing training for the health care providers for continuous updation of knowledge and skills.