Working together for better lung health

Respiratory diseases are responsible for one in five deaths globally. Most respiratory diseases are treatable or preventable, but in many low and middle income countries (LMICs), high levels of pollution and tobacco smoking, combined with low awareness of lung disease, puts millions more at risk of avoidable ill health and death. 

Dr Hana Mahmood of Neoventive Solutions, a research centre in Pakistan, is one of a network of clinicians and scientists working with the NIHR Global Health Research Unit on Respiratory Health (RESPIRE). In Pakistan, pneumonia kills almost 100,000 children under five every year, even though it is preventable and treatable. As part of RESPIRE’s wider pneumonia prevention project in Pakistan, Dr Mahmood’s study trained over 30 community health workers in a rural community of Islamabad to help more than 1,000 families understand the symptoms of pneumonia and the urgency of seeking treatment. 

Dr Mahmood said: “We engaged with communities to explore the perceptions of infant pneumonia and reasons why caregivers delay seeking medical care. We trained community health workers to bridge the gap between the community and healthcare system by using mobile phones to encourage families to seek timely treatment for their children by educating them on pneumonia and its prevention.” 

Over the past five years, RESPIRE’s researchers have been working closely with patients, healthcare professionals and policy-makers in countries across Asia, to find out how respiratory diseases affect their local communities. They organise community meetings, school-based programmes and smoking cessation events to raise awareness and engage people with specific projects. Public input helps develop interventions that are specific for those communities, as was the case in Malaysia where researchers wanted to dispel myths and stigma around asthma. 

In the Klang Valley, Malaysia, working alongside adults and children living with asthma, the team produced videos and comic-style information books for children to raise awareness and understanding of the condition. Dr Tracy Jackson, RESPIRE’s Community Engagement and Involvement Research Fellow, said: “Our approach is to work with existing local research groups to enable better provision of resources and allow our partners to build capacity, which will continue to benefit our network’s countries and communities in the future.”

These projects are some of many examples of how RESPIRE’s work across Asia has helped cut death rates from respiratory conditions and reduce the impact of such illnesses on people’s lives. RESPIRE is based at the University of Edinburgh, which works in collaboration with ten partners across Bangladesh, India, Malaysia and Pakistan, on both infectious respiratory diseases, like pneumonia, that affect children, and chronic respiratory diseases, such as asthma, lung cancer and chronic obstructive lung disease (COPD). 

 “RESPIRE has brought together an outstanding group of scholars, clinical academics and early career researchers who have worked in partnership with health policy makers, leaders of health systems and professional bodies, and members of the public to generate important new insights on how best to advance and promote respiratory health across Asia in equitable ways.”

Aziz Sheikh, Professor of Primary Care Research and Development, University of Edinburgh and Director of the NIHR RESPIRE Unit

Chronic respiratory diseases are common across the world but the majority of deaths and disability occur in LMICs, often because they lack the resources to diagnose the condition. In a joint project across the four partner countries, RESPIRE reviewed the use of screening procedures to understand the prevalence of asthma and COPD, which will help LMICs develop health policies and take steps toward providing communities with the respiratory care resources they need. Their results were published in the Journal of Global Health.  

In Tamil Nadu in India, a RESPIRE intervention identified nearly 300 people with a potential chronic respiratory disease, of which 200 were later confirmed by a primary care provider. As a result, 70 physicians and community nurses across charity hospitals in the Tamil Nadu region received training to deliver RESPIRE’s intervention for rural and often hard-to-reach populations.

Professor Ee Ming Khoo of the University of Malaya, Malaysia, and co-lead of RESPIRE’s chronic respiratory disease programme, explained how the programme’s work is improving healthcare in Asia: “We raised awareness of respiratory diseases, in particular asthma and COPD, among patients, healthcare workers and policymakers and identified gaps and strategies to improve access to care and improve equity in vulnerable populations. This included palliative care for people with severe COPD and home pulmonary rehabilitation programmes for people with chronic respiratory disease, both of which services were either scarce or non-existent in the country.” 

A key element of RESPIRE’s acute respiratory disease programme was to adapt and incorporate existing interventions into partner countries’ healthcare systems, taking account of each country’s needs. New interventions were developed and tested in small-scale trials, with a view to carrying out larger trials if they were effective. 

“The multi-country initiative of RESPIRE is not only preventing deaths and illness from respiratory diseases in low and middle income countries but also providing higher education to young scientists, with the support from NIHR."

Professor Samir Saha, co-lead of RESPIRE’s acute respiratory disorders programme and Director of the Child Health Research Foundation in Bangladesh

Highlighting the need for locally appropriate approaches, a RESPIRE project based in Maharashtra State, India, found that the adult population appears to have lower lung volumes compared to Europeans or North Americans. Using the standard measurement for lung function, spirometry, with its predictive values for European and North American adults could lead to overdiagnosis of lung disease in this area of India. The RESPIR team developed specific spirometry predictive values for the local population and is now working with other Indian sub-groups to ensure they too have appropriate predictive values, which might also be important for diaspora populations. The study’s results were published in the European Respiratory Journal. 

Another project in the Kushtia district of Bangladesh investigated the feasibility of introducing pulse oximetry (a non-invasive method to monitor a person’s blood oxygen level) in outpatient and primary care clinics to identify children with pneumonia earlier and more accurately. Low levels of oxygen in the blood indicate that pneumonia has worsened and the patient needs life-saving treatment. On completion of this project, Bangladesh’s Ministry of Health and Family Welfare trained nearly 5,000 health workers to use pulse oximeters in Bangladesh’s routine child health services, helping to save children’s lives through earlier diagnosis. A similar RESPIRE project is now underway to bring pulse oximetry into more general practice in India. 

The Covid-19 pandemic brought new challenges for RESPIRE’s partner countries, and the Unit co-ordinated additional research to understand and manage the unique situations they faced. For example, the team evaluated the use of a simple salt water solution to lessen the symptoms of Covid-19 in Pakistan. In India, RESPIRE funded the recruitment and data collection of 11,000 people to estimate the number of people with antibodies against coronavirus. This helped to measure the level of population immunity due to past infection or vaccination and informed the Covid-19 response. 

The Unit has supported LMIC researchers’ development of new skills and expertise by providing a range of post-graduate training courses and funding PhD students to study with the University of Edinburgh while carrying out research in their countries. 

By focusing on the unique local challenges in each partner country, the Unit’s research has delivered real benefits for patients, health practitioners and policy makers and is taking steps to scale-up its research efforts over the coming years. 

RESPIRE investigators have led the formation of the Global Health Respiratory Network, which brings together respiratory health experts from ten NIHR Global Health Research Groups and Units. The network’s focus is to increase research activity around respiratory disorders, deliver effective interventions and build upon skills in LMICs to improve the respiratory health of the world’s most vulnerable people.   

Research from the Unit has been published widely, including a review of the global prevalence of COPD in The Lancet Respiratory Medicine. The team has also presented at numerous local and international conferences, adding to the evidence base around respiratory diseases in LMICs. Several RESPIRE members have been recognised for their role in improving public health, with Professor Samir Saha being awarded the second highest civilian award in Bangladesh, the Ekushey Padak and Dr Hana Mahmood winning the Woman of Wonder Award in Public Health in Pakistan. 

Reflecting on the RESPIRE programme’s progress and achievements, Professor Aziz said: 

“RESPIRE has enabled us to accelerate and extend our work with low and middle income country partners around the world to tackle major respiratory health challenges faced by the world’s most deprived populations.” 

“I’m particularly proud of how our RESPIRE collaboration has been able respond to the Covid-19 pandemic – not only in keeping vitally important respiratory projects on the road, but also the speed with which we were able to initiate a range of urgent Covid-19 projects aiming to mitigate the effects of the pandemic in resource poor settings. We have an excellent foundation on which to now build as we work to tackle the high levels of respiratory morbidity and mortality in Asia.”    

More information about the study is available on the NIHR’s Funding & Awards website.