Pulmonology · Medical Literature
The Feasibility and Acceptability of Culturally Appropriate Pulmonary Rehabilitation for Adults with Chronic Obstructive Pulmonary Disease in Sri Lanka: Randomized Controlled Trial.
Abstract
Pulmonary rehabilitation (PR) is recommended internationally for individuals with chronic obstructive pulmonary disease (COPD), but there is limited evidence and practice of PR in Sri Lanka. Key challenges for PR such as poor accessibility, uptake and completion need to be addressed when designing and delivering new PR programmes. Accordingly, this study determined the feasibility and acceptability of culturally adapted PR for adults with COPD in Sri Lanka. A randomized controlled feasibility trial was conducted with 50 adults living with COPD in Colombo, Sri Lanka. A culturally adapted PR comprised a 6-week rolling programme with sessions conducted twice every week. Sessions involved endurance and resistance exercise training, education and cultural adaptations of nutritional support and group singing. The control group received usual care, which did not include any form of PR or exercise training. Feasibility was determined by uptake (≥60% of eligible participants consented) and completion (≥70% of recruited participants). Acceptability was explored by focus group discussions (FGDs) analysed thematically. Seventy-nine eligible individuals (94% of screened) were referred in order to recruit 50 participants (63% uptake). The majority of participants in both intervention (72%, n=18) and control (64%, n=16) groups completed the study. Based on qualitative focus group discussions four themes emerged: (1) Increased knowledge following PR, including dispelling misbeliefs about COPD and improving medication adherence; (2) Perceived improvements in health following PR, including improved walking ability and reduced breathlessness (3) Enjoyment and benefits of cultural adaptations to PR, and (4) Challenges during PR, including adherence to exercise and travel requirements. Culturally adapted PR was feasible and acceptable to adults with COPD in Sri Lanka. A fully powered trial is warranted for evaluating clinical and cost-effectiveness of culturally adapted PR.
Clinical relevance
Is a culturally adapted pulmonary rehabilitation (PR) programme feasible and acceptable for adults with COPD in Colombo, Sri Lanka, as measured by pre-specified uptake and completion thresholds and qualitative participant experience? __SNAPSHOT__ {"studyDesign":"Randomized controlled feasibility trial (parallel-group, 1:1 allocation)","setting":"Central Chest Clinic, National Hospital of Sri Lanka, Colombo, Sri Lanka (single urban tertiary centre)","sampleSize":"n=50 randomized (intervention: 25, control: 25); 79 eligible individuals referred to achieve enrolment target","population":"Adults living with COPD referred by physicians at a tertiary chest clinic in Colombo; 94% of those screened were eligible. Detailed age, sex, spirometric severity, and comorbidity data not reported in the available abstract.","intervention":"Culturally adapted PR: 6-week rolling programme, twice-weekly sessions comprising endurance and resistance exercise training, disease education, nutritional support, and group singing adapted to the Sri Lankan cultural context (12 sessions total)","comparator":"Usual care (no PR, no structured exercise training)","primaryOutcome":"Feasibility: uptake (≥60% of eligible participants consented and attended first PR session) and completion (≥70% of recruited participants completed the programme). Acceptability was explored as a co-primary outcome via focus group discussions (FGDs) analysed thematically.","followUp":"6 weeks (programme duration); longer-term follow-up not reported","fundingSource":"Not reported in available abstract; institutional affiliations include University of Leicester and University Hospitals of Leicester NHS Trust (UK) with Sri Lankan academic co-investigators, suggesting mixed international academic support"}
Key findings
Of 79 eligible individuals (94% of those screened), 50 were recruited, yielding an uptake of 63%—meeting the pre-specified feasibility threshold of ≥60%. Completion was 72% (n=18/25) in the PR group and 64% (n=16/25) in the control group; the intervention arm met the pre-specified completion threshold of ≥70%, while the control arm fell marginally below this threshold. No p-values, confidence intervals, or effect sizes for clinical outcomes (e.g., exercise capacity, dyspnoea, health-related quality of life) were reported in the available abstract, consistent with the study's feasibility rather than superiority design. Qualitative analysis of FGDs identified four themes: (1) increased knowledge following PR, including dispelling misbeliefs about COPD and improving medication adherence; (2) perceived improvements in health, including improved walking ability and reduced breathlessness; (3) enjoyment of and perceived benefits from cultural adaptations (group singing, nutritional support); and (4) challenges during PR, including adherence to exercise requirements and travel burden. No adverse events were reported in the available abstract.
Practice implications
This feasibility trial established that a culturally adapted PR programme can be recruited for, delivered, and completed in an urban tertiary chest clinic in Sri Lanka, meeting pre-defined thresholds for both uptake (63% vs. ≥60% threshold) and programme completion in the intervention arm (72% vs. ≥70% threshold). The study was explicitly not powered or designed to detect differences in clinical efficacy outcomes (exercise capacity, dyspnoea, HRQOL); such outcomes were not reported and no inferential comparisons between arms should be drawn. Qualitative data suggest cultural adaptations—particularly group singing and locally contextualised nutrition advice—were perceived by participants as meaningful additions that enhanced engagement. The findings apply to adults with COPD attending an urban tertiary chest clinic in Colombo; generalisability to rural Sri Lanka, other South Asian LMIC settings, or more severe or comorbid patient populations cannot be assumed. Women, older patients, and those with severe airflow obstruction or significant comorbidities were not described as explicitly included or excluded, limiting characterisation of representativeness. Practice should not change based solely on this trial; rather, these results provide sufficient evidence of feasibility and acceptability to justify proceeding to a fully powered definitive RCT evaluating clinical effectiveness. Only the abstract was available for review, which is an important limitation of this summary. __LIMITATIONS__ Single-centre urban tertiary setting (Central Chest Clinic, Colombo) severely limits external generalisability to rural or lower-resource settings within Sri Lanka and to other LMICs.,Small sample (n=50) is appropriate for a feasibility trial but precludes any inference about clinical efficacy, effectiveness, or safety.,No clinical efficacy outcomes (6-minute walk distance, shuttle walk, dyspnoea scores, HRQOL instruments) were reported in the available abstract, meaning effectiveness remains entirely unestablished.,Short 6-week follow-up provides no information on durability of benefits or long-term adherence.,Control group completion (64%) fell marginally below the pre-specified ≥70% threshold, raising questions about usual care engagement and potential contamination or differential dropout.,Lack of blinding is inherent to exercise rehabilitation trials but introduces performance and detection bias, particularly for subjective qualitative outcomes.,Qualitative acceptability data are subject to social desirability bias, as participants may have reported positive experiences to investigators who delivered the programme.,Detailed participant demographics, COPD severity staging, spirometric data, and comorbidity profiles are not reported in the abstract, limiting assessment of population representativeness.,Funding sources and potential conflicts of interest are not reported, precluding assessment of sponsorship bias.,Only the abstract was available; full methodological detail (randomisation concealment, allocation sequence, analysis population definitions, adverse event monitoring) could not be assessed. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ A culturally adapted pulmonary rehabilitation programme incorporating group singing and locally tailored nutrition education met pre-specified feasibility and acceptability thresholds in a small single-centre RCT in Colombo, Sri Lanka, with 63% uptake and 72% completion in the intervention arm. Clinical efficacy outcomes were not assessed in this feasibility trial, and practice should not change on the basis of these data alone. These results support progression to a fully powered definitive RCT to evaluate whether culturally adapted PR produces clinically meaningful improvements in exercise capacity, dyspnoea, and health-related quality of life in Sri Lankan adults with COPD.