FRESH AIR: a implementation science research project to improve the prevention, diagnosis and treatment of non-communicable lung diseases in low and middle income countries (LMICs) and other low-resource settings

Around 90% of deaths from COPD and 80% deaths from asthma occur in low and middle-income countries (LMICs). FRESH AIR, acronym for Free Respiratory Evaluation and Smoke-exposure Reduction by primary Health cAre Integrated gRoups, is a three year project that addresses the urgent need to prevent, diagnose and treat non-communicable lung diseases in low and middle income countries (LMICs) and other low-resource settings where the greatest burden of disease occurs. Over the next 3 years FRESH AIR will explore why so many people in LMICs are dying from chronic lung diseases and what can be done to reduce the burden. A set of implementation science studies will examine the burden of chronic lung diseases, their risk factors, public awareness of these risk factors and how evidence-based approaches to prevention, diagnosis and treatment can be implemented in affordable and appropriate ways.

Health outcomes for people at risk of or suffering from non-communicable lung diseases in low-resource settings will be improved by developing capacity for implementation of evidence-based interventions for prevention, diagnosis and treatment in these contexts.

This study will consist out of five sub studies.

The first substudy will focus on the improving of diagnosis and treatment of lung diseases by supporting training and implementation of lung function measurements through delivery of an online spirometry training and feedback program in low-resource settings (will be referred to as spirometry study)

The second study is a development study to examine feasibility and acceptability of very brief advice on smoking (VBA) training for healthcare workers. It main aim is to determine whether the VBA on smoking intervention can be adapted to the healthcare context in the four partner countries; and whether training health and social care workers in delivering the intervention results in a change to their clinical practice. (will be referred to as VBA study)

The third study examines the feasibility and acceptability of a pulmonary rehabilitation intervention. (will be referred to as pulmonary rehab study)
The fifth study is a qualitative, clinical study assessing respiratory symptoms and asthma in children under five years (U-5's) of age in low-resources settings. Thereby aiming to obtain comprehensive knowledge on respiratory health practices in order to strengthen the diagnosis and treatment of respiratory distress in children in primary health care in and thereby reduce respiratory morbidity and mortality. (will be referred to as U'5 study)

The fourth study is aimed at assessing the feasibility and acceptability of a midwife-led health education intervention aimed at reducing exposure to HAP among pregnant women through a train the trainer programme delivered by midwives. This will be a development project and the information that will be generated will inform a larger study that will aim to assess the impact of interventions to reduce biomass exposure among pregnant women on pregnancy outcomes and lung health during infancy. (will be referred to as midwife study)

All studies will be conducted parallel to one another in the health care sector of rural areas in Greece, Kyrgyz Republic, Uganda and Vietnam. With the exception of the midwife study which will only be conducted in the rural areas of Uganda.

Spirometry study

- continuous data collection on outcomes 2 and (month 2-5)

- outcome 1, after Spirometry 360 training

VBA study

- pre training, baseline knowledge (T0)

- post training, knowledge (T1)

- post training, program evaluation (T1)

- post training self-report VBA delivery (T2)

- post training, after 4 weeks, smoking status participants (T2)

Pulmonary rehab study:

- baseline (T0)

- beginning of each rehab program session (T1-12)

- Post-rehab program, evaluation (T13)

U-5s study

As it is an observational sub study, no fixed time points have been set. Data will be collected throughout the predefined period of data collection.



Midwife study:

information on acceptability and feasibility of the midwife program and supporting material will be assessed throughout the predefined period of data collection.

- post training, evaluation satisfaction

Spirometry study:

A Spirometry 360 online training and feedback program, consisting out of a series of Spirometry 360 activities. No control intervention will be admitted or implemented.



VBA study:

A Very brief advice training module translated and adapted to the local language, context and need.



Pulmonary rehab study:

A pulmonary rehab training module translated and adapted to the local language, context and needs. The format of the rehabilitation program with supporting materials , patient information resources and web-based information will be based on the outcome of the development study conducted in Uganda and funded by the Medical Research Council (MRC), the Welcome Foundation and the Dept. of Overseas Affairs in the UK (expected end date: February 2016). The Group-based program will consist of 6-week, twice weekly pulmonary rehabilitation programme consisting of physical exercises and health education, led by a physiotherapist and held in health centre.

U-5's study:

No intervention will be held, as it involves an observational sub study

Midwife study:

a health education programme to create and/or increase awareness about lung health and reduction of exposure to biomass smoke in pregnant women and children. The program is drafted and developed with help of the local midwives, paediatric nurses and research team.