Title: NIHR Global Health Research Unit on Lung Health and Tuberculosis in Africa at LSTM
Funder: Department of Health and Social Care

Abstract: STRATEGIC AIM To improve the health of children and adults in Africa through multi-disciplinary applied health research on lung health and TB. HOW THIS WORK WILL BUILD ON LSTM STRATEGY LSTM's vision is to save lives in resource poor countries through research, education and capacity strengthening. The work the Unit will conduct and co-ordinate has the LSTM mission at its core: to reduce the burden of sickness and mortality in disease endemic countries through the delivery of effective and affordable interventions which improve human health for the poorest communities. LSTM's track record of successful development of scientific advances and their translation into evidence-based policies and practices is underpinned by collaborative multi-disciplinary work in over 70 countries. The proposed NIHR Global Health Research Unit in applied lung health and TB research will add value to high-level LSTM strategy and benefit from a thriving, internationally-excellent global health research environment. WHY LSTM IS WELL PLACED TO MAKE THIS APPLICATION LSTM is uniquely positioned with a critical mass of internationally excellent clinical and applied health scientists with expertise in lung health and TB in the tropics. There is considerable momentum within applied global health research at LSTM - e.g. LSTM has made several senior academic appointments over the last 5 years to provide global health research leadership in this area. CAHRD was established in 2012 to create a global network of individuals, disciplines and organisations to facilitate both applied global health research and the development and evaluation of interventions to transform health systems and improve health for people in LMICs. CAHRD is led by LSTM in collaboration and partnership with individuals and organisations from over 20 LMICs. This application will leverage these various investments and substantially scale-up our capacity to deliver impact through world-leading multi-disciplinary applied global health research. EXISTING LSTM PARTNERSHIPS AND STRATEGIES Existing collaborations and partnerships have been included in this proposal where they have synergies with the overall theme of lung health and TB. The Unit will generate new applied health research findings that are policy- and practice-ready on the closely interlinked themes of non-communicable respiratory disease, TB, acute presentations of respiratory disease, and air pollution and tobacco-related disease through multi-disciplinary (clinical, applied social science, health systems, health economics, modelling, policy, delivery and impact) work. It will invest strategically in building capacity and capability through 5 PhD studentships for African students, adding value to our existing LSTM-led MRC funded Doctoral Training Programme in Global Health, as well as in 5 post-doctoral scientists based in LMIC partner organisations or at LSTM. Strengthening LMIC partner research infrastructure and individuals’ skills at all levels will help ensure future sustainability of investments in capacity and capability. PROPOSED PROGRAMME OF RESEARCH Non-communicable lung diseases, TB and acute presentations of lung disease account for 3 of the top 5 causes of death worldwide, disproportionately affecting the world's poorest people (1-4). The inhalation of polluted air, including tobacco smoke, causes 13 million deaths globally a year (5-7). The co-existing burdens of communicable and non-communicable lung disease bring special challenges to health systems adapting to epidemiological and socioeconomic transitions in LMICs (8-10). We will develop and evaluate integrated, multi-disciplinary approaches in intervention development, evaluation and implementation research to meet these challenges, and address the SDGs for health including reducing premature mortality from non-communicable diseases (NCD), TB and air pollution. Our outputs will also help achieve the goals of Universal Health Coverage (11,12). Strategic research objectives: 1. Develop and evaluate: (i) effective and affordable strategies to promote and sustain behaviours and environments which protect lung health especially amongst the most vulnerable groups. (ii) equitable approaches that will see patients with respiratory conditions receive accurate diagnoses, essential, effective and affordable treatments, care and support at community and facility level. 2. Elucidate the concerns, priorities and experiences of affected individuals, households, communities and providers at different levels to inform appropriate interventions and strategies. 3. Sustainably strengthen infrastructure and systems for multi-disciplinary applied health research in 17 organisations across 11 countries, to act as African hubs for developing and delivering this work. 4. Identify strategic priorities for applied health research for equitable programmes in lung health and TB in Africa and strategies to address them over the 10 to 20-year horizon. Aims and objectives: 1-2 years 1. Launch Unit in Africa at start-up meeting of investigators for a recently awarded MRC GCRF grant 'Lung health in Africa across the life course' in Malawi in July 2017. 2. Finalise protocols for, peer review (by international partners and External Scientific Advisory Panel [ESAP]) and initiate 1st wave of research projects (PhD and post-doctoral) that address Unit strategic research objectives. 3. Hold CAHRD conference hosted by National Institute for Medical Research, Tanzania in 2018 to build networks, showcase partner research and elicit African policy and practitioner perspectives on priority challenges and potential solutions. 2-3 years 1. Complete and disseminate findings of 1st wave of research projects. 2. Review progress against strategic objectives with ESAP to inform future directions and priorities. 3. Develop, peer review and initiate 2nd wave of research projects in response to review. 3-4 years 1. Establish a sustainable funding strategy for Unit activities in collaboration and partnership with African national processes, governments and institutions. 2. Maximise uptake and impact of multi-disciplinary findings through synthesis and targeted dissemination activities. 3. Develop a cadre of African post-doctoral researchers with multi-disciplinary expertise relevant to lung health and TB, through completion of PhD studentships and support to further career development. 4. Develop 17 African sites with critical mass in and improved systems for multi-disciplinary policy- and practice-relevant research in lung health and TB. Proposed projects to be pursued in the first 2 years: 1. Develop and pilot integrated clean air interventions building on our JGHT-funded clinical trial that found no reduction in pneumonia risk in under 5s in rural Malawi of a cleaner-burning cookstove intervention vs traditional open fire cooking (13). 2. Investigate the impact of air pollution exposures on lung health through childhood, adolescence and adulthood. 3. Develop an approach that links community perspectives and need with public priority setting processes for interventions to promote lung health in specific contexts. 4. Develop and pilot innovative and responsive outreach services that extend equitable access to close-to-community diagnosis, treatment and support for lung health and improved quality of life; approaches will include affordable point of care diagnostics and the practical approach to lung health in communities. 5. Determine impact of lung diseases on household expenditure, socio-economic status, wellbeing, and quality-of-life compared to healthy households - measurements, determinants and coping mechanisms over time for baseline and impact assessments. INVOLVEMENT OF COLLABORATORS AND PARTNERS Our research agenda arises from several decades of multi-partner, multi-country North-South collaboration. Partners and collaborators on this proposal participated in a CAHRD consultation in Liverpool in 2014 to scope the major applied health research challenges in the coming 10-20 years and the scientific questions to be answered to deliver solutions. The consultation centred around priority topics including health systems, capacity strengthening and lung health. The proceedings of the consultation have been published (14-21). The Unit will build on 3 applied health research areas (lung health, health systems, and capacity strengthening) addressed in the CAHRD consultation. These resonate with global priorities including the SDGs and the End TB Strategy. They also utilise the major research strengths of the applicants and associated networks including the WHO Social Protection Action Research & Knowledge Sharing (SPARKS) network whose current focus is lung health. COMMISSIONED RESEARCH None. RESPONSIVE CAPACITY All routine and planned Unit activities will have written contingency plans enabling staff and resources to be redirected at short notice in response to emerging global health research requirements. A global health emergency requiring a rapid response from our Unit will trigger an urgent assessment, decision making and planning meeting of our leadership and management teams to ensure the most appropriate and timely responses. LSTM has a successful track record in this regard (e.g. Ebola response in Sierra Leone). SUSTAINABILITY PLANS Success and sustainability of the Unit will require further successful grant applications and strengthened research capacity among all partners. Whilst core Unit grant funding is needed at this stage to substantially scale-up our activity, we will include in our strategic plan a future model of funding (e.g. a budget contribution towards Unit support within grant applications) and continued strategic capacity development that will allow us to sustain impact beyond the duration of NIHR funding

Lay abstract: The International Multidisciplinary Programme to Address Lung Health and TB in Africa “IMPALA” is a 4-year collaborative programme led by LSTM. Objective: To advance existing scientific knowledge and generate new data and implementable solutions for lung health & TB through a multi-disciplinary collaborative approach. We will deliver our work via 8 research projects, 3 at postdoc level led by 5 PDRAs and 5 at PhD level, involving 5 disciplines (in capital letters) PDRA projects: 1. SOCIAL SCIENCES & HEALTH SYSTEMS: integrated approach for improving health services for chronic lung disease in Sudan & Tanzania. 2. CLINICAL SCIENCES & HEALTH ECONOMICS: clinical and socio-economic determinants of lung function among infants in Uganda. 3. POLICY/CAPACITY RESEARCH: Multidisciplinary cross-cutting capacity research project (MUDI) looking at how IMPALA fosters research involving multiple disciplines in different contexts. PhD projects: 1. CLINICAL SCIENCES: Is clinician performed ultrasound assessment useful for the acutely breathless adult patients in Kenya? A pilot pragmatic Randomised Controlled Trial 2. SOCIAL SCIENCES: Patient and health worker needs to improve health literacy, effective communication and patient support for adult TB patients and patients with chronic respiratory symptoms in public health facilities in Kampala, Uganda 3. HEALTH SYSTEMS: Improving referral uptake and tracking for lung disease and TB within the devolved healthcare system in Kenya 4. HEALTH ECONOMICS: Assessing the economic burden of non-communicable lung disease and the impact of patient-oriented interventions amongst adults in Malawi 5. POLICY: Evaluating the impact of operational modelling on TB and lung health policy and practice in Sub-Saharan Africa Research Capacity in Africa To ensure this is built and retained in-country, we work collaboratively with scientists from 22 institutions from 14 countries: - 19 partners help implement the 8 projects mentioned above. 16 are based in Africa (Cameroon, Ethiopia, Ghana, KENYA, MALAWI, Nigeria, South Africa, SUDAN, TANZANIA, UGANDA) 3 in HICs (2 UK and 1 NZ) - 3 sub-contractors deliver specific pieces of work: Lancaster Uni deliver the MRes in Quantitative Skills in Global Health in yr 1; the Global Asthma Network prepare the annual Global Asthma Report; and BOLD analyse data from their centres - 3 collaborators: American Thoracic Society (US), Vital Strategies (US) and The Union (France) offer expertise in-kind. We expect to generate benefits to: 1. Patients, health systems & communities in Africa by developing interventions to improve treatment pathways for patients with chronic and acute lung disease; identifying modifiable determinants of poor lung function among adults and children; improving health literacy and communication within lung health care systems; improving health outcomes for acutely breathless patients through improved diagnosis & treatment. 2. African researchers through collaboration, mentoring and support and the development of a vibrant and engaged network of African researchers spanning the continent. 3. Policy makers & key stakeholders through building their understanding of the key issues determining lung health and treatment, engaging them prospectively in the design of research and through the generation of policy relevant knowledge, strategies & interventions.

Research activity codes: 7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT)
Health categories: INFECTION;RESPIRATORY