Title: NIHR Global Health Research Group on improving asthma outcomes in African children at Queen Mary University of London
Funder: Department of Health and Social Care

Abstract: A strategic aim of the Blizard Institute at Queen Mary University of London (QMUL) is to support research into non-communicable diseases, including asthma. Embedded in the Blizard Institute is the Asthma UK Centre for Applied Research, This Centre was launched in 2014, with the specific aim of improving the quality of life of people with asthma. The Blizard Institute aims to generate knowledge via research that is not only applicable to UK populations, but also to populations in low and middleincome countries. For example, it currently hosts major research programmes in Zimbabwe, Malawi, Ethiopia, South Africa, Mongolia, and Bangladesh - and is part of the Wellcome Trust Bloomsbury Centre for Global Health Research, and administers the Wellcome Trust’s Clinical PhD Programme in Global Health Research. The Blizard Institue's infrastructure is ideally suited to support this proposed Global Health Research Group. First, it is the largest institute of Barts and the London School of Medicine and delivers excellence in all aspects of research, teaching and clinical service. Second, it supports 460 full time staff, 83 postdoctoral fellows, and 169 PhD/MD students. Third, it fosters multidisciplinary research with academic expertise (within the same building in Whitechapel) ranging from basic science, to primacy care, epidemiology, and child health. The Institute is part of the QMUL’s School of Medicine and is internationally recognised with more than £60 million per year in research income. Indeed, the School of Medicine was placed within the top 7 UK institutions in all three relevant Units of Assessment in the last Research Excellence Framework exercise. If funded, the Blizard Institute will donate all infrastructural support and applicants’ time. Our partnership via Dr. Rylance with the Malawi-Liverpool-Wellcome (MLW) Trust Clinical Research Programme delivers a major African Research Centre that conducts internationally excellent science with a focus on sub-Saharan Africa. It is built around world-class laboratories, strategically located in the largest hospital in Malawi, and closely linked with the local community. Its partnership with the Malawi Ministry of Health, ensures that research is rapidly translated to improving human health outcomes. In addition, the focus of MLW on lung health spanning both community and hospital, maps to the aims of this Group. Our link via Mortimer with the Liverpool School of Tropic Medicine, delivers a wide range of other partnerships including the Liverpool-Glasgow Centre for Global Health Research, the Wellcome Trust. Mortimer, Rylance, and Grigg, are members of the MRC-BREATHEAfrica partnership, with its focus on improving children’s health across Africa by reducing air pollution. Prof. Refiloe, as Secretary of the Pan African Thoracic Society (PATS), delivers to this Group a network of over 1000 respiratory clinicians across the continent of Africa. She will ensure that the PATS network is available for advice and dissemination. Prof. Grigg as Head of the Paediatrics Assembly of the European Respiratory Society (ERS), delivers a global network of over 2000 respiratory paediatricians, with ERS support for publications, research workshops, public engagement, and advocacy. A formal partner of this Group is the World Health Organization (WHO), via Dr. Nils Billo, the WHO medical officer responsible of management of Chronic Non-Communicable Respiratory Diseases, and liaising with the Global Alliance Against Chronic Respiratory Diseases. Dr Billo is currently responsible for the update of the Global Action Plan for the prevention and control of non-communicable diseases. Prof. Fortune is part of the steering group of the Global Knowledge Exchange Network (GKEN) consisting of academics in the UK, USA and Europe who work to support teaching and training via mobile phone technology across several African countries. This project responds to the concerns of international bodies such as the WHO and the Global Asthma Network (GAN), and to our African applicants’ research that has identified paediatric asthma as a high priority in their urban areas. For example, Dr. Adeyeye in Lagos found that only 10% of over 1000 Nigerian secondary school teachers had good knowledge of asthma (Am J Resp Care Med 2017:195:A7650), Dr. Natanda found that 41% of preschool Ugandan children presenting to hospital with difficulty breathing had asthma (PLoS One 2013, e81562), and Prof. Addo-Yobbo, in a study done in secondary schools in Ghana, found that the prevalence of exercise-induced asthma in children has doubled over a 10 year period (PLoS Med. 2007;4(2):e70). The school- and hospital-based surveys will be adapted from the UK online survey of asthma control and knowledge that we developed and delivered to over 700 asthmatic children in London secondary schools during 2015 -16. We will hold focus group discussions involving African children in schools with asthma to adapt the survey, and feedback on the theatre intervention, and adapt the UK schoolsbased intervention for African populations. Areas to be covered by these focus groups of children include general confidence and empowerment regarding asthma self-management, adherence to medications, inhaler technique and spacer usage, recognition of triggers, emergency response to asthma attacks, and communication with peers, teachers, and health professionals. We will also seek partnerships with other researchers who have done school-based research, such as those from Makerere University (Uganda) who, in a cluster-randomised controlled trial that recruited 143 teachers and 10,813 children from 120 schools in central Uganda, found that delivery of information to teachers resulted in a large improvement in the ability of children to assess claims about the effects of treatments (Lancet 2017;390:374-388). To ensure that research is co-designed with stakeholders, we will draw on the African Centre clinicians’ own local networks of teachers, parents, pharmacists, clinicians, and allied health professionals. Children with asthma, via focus groups will co-design and advise on delivery of our asthma research. Their views will be formally captured by using qualitative research methodology identical to that used when designing our London school-based asthma intervention.

Lay abstract: Previously, asthma in African children was not thought to be a major health issue. But as more African children move to urban areas, they are developing this long-term disease. Recent surveys done in African schools have found that the proportion of children aged 13 to 14 years who have ongoing symptoms of asthma is between 10 to 20% in Central Africa, increasing to over 20% in South Africa. But to date, a lack of asthma research and research infrastructure means that we do not have the evidence to either inform advocacy or to develop interventions that improve asthma outcomes. For example, the degree of asthma symptoms (asthma control) has not been assessed by any school survey in African children - these previous surveys have focussed only on identifying the proportion of children with asthma symptoms. However, a recent report from the Global Asthma Network (GAN) speculated that asthma control in African children is poor and that this is not just due to affordability of asthma inhalers, but due to lack of diagnosis, poorly coordinated asthma management, a lack of asthma knowledge in children, teachers and parents, and stigma associated with this long-term condition. The proposed Global Health Research Group comprising of clinical academics in South Africa, Ghana, Uganda, Malawi, Zimbabwe, Nigeria, and London (Queen Mary University of London, QMUL), will therefore identify how many children aged between 12 and 14 years with asthma symptoms have i) been diagnosed, and ii) how many of these have poor control. The survey will be adapted from an online survey that we have delivered to asthmatic children in London schools. In African children with asthma, we will also identify the barriers to achieving good control from the survey itself and from subsequent focus groups. From this, we will develop a low-cost school-based intervention aimed at addressing these barriers. To achieve this, we will adapt our UK online schoolsbased survey of asthma control and knowledge and attitudes to asthma so that it is appropriate for assessing African children with asthma. Using this survey in London secondary schools, we found that 46% of over 700 children with asthma had suboptimal control, but 42% of these actually thought that their asthma was well controlled. Many London children with asthma said they felt misunderstood; some feared ridicule and others reported being bullied about taking inhalers. The adapted online survey will be completed by 3000 asthmatic children (12 to 14 years) in schools across 6 urban and rurban Centres in Africa. Children who do not attend school will be identified from those attending hospital for an asthma attack, and the survey completed in hospital clinics. Informed by the survey’s result we will use focus groups to adapt our UK-based schools-intervention for children with asthma, which is designed to address the barriers to achieving good asthma control. We will deliver and assess one component of our UK school asthma intervention in African schools, a play delivered in schools addressing stigma and asthma knowledge, after adaption for African children. The theatre intervention will be delivered in schools by local actors and the change in attitudes of children with asthma, peers, and teachers assessed. All African researchers will be provided with training, supervision, and direct support to deliver this project. Underpinning this research will be an innovative data capture and management system developed at QMUL that uses enhanced low-cost mobile technology.

Research activity codes: 7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT);8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: RESPIRATORY