Title: NIHR Global Health Research Group on Global COPD in Primary Care, University of Birmingham
Funder: Department of Health and Social Care

Abstract: JUSTIFICATION OF INSTITUTE APPLICATION The University of Birmingham (UoB) has global ambitions around the reach and impact of its research, based on effective engagement and collaboration with partners to inform, utilise and contextualise its research. Alongside this broad strategy UoB also supports focused engagement in several key strategic regions including China and Brazil (two of the partners in our bid). The Institute of Applied Health Research (IAHR) hosts the multidisciplinary COPD research group (2005), led by Adab/Jordan. The group has a growing international reputation with current core research funded by an NIHR programme grant (~£2.4m), focusing on earlier identification & development of interventions to improve prognosis and work productivity in UK COPD patients. The team includes experts in respiratory epidemiology, biostatistics, health economics, qualitative research. Collaboration with other IAHR and UoB colleagues provides access to additional expertise, including respiratory medicine, physiology, global research. Cheng (applicant) established one of the first academic GP departments in China. SUPPORT FROM UOB Our campus-based International Office, China Office (Guangzhou) & Brazil Office (Sao Paulo) will facilitate collaborative working with international partners (eg links to healthcare providers/government departments, assisting organisation of stakeholder meetings). UoB will support this research by subsidising input from senior academics (especially development/delivery of training), provision of office/facilities & general research support. In recognition of the importance of these partnerships, UoB will provide honorary contracts to international partner co-applicants, allowing access to resources eg e-journals. To support sustainability post-grant, UoB will deliver a workshop for co-applicants after the end of the project and support further grant application development for future work in this important area. PROPOSED PROGRAMME: BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is an increasingly important chronic respiratory disease. Disease burden disproportionately affects the most disadvantaged populations in LMICs [1-4]. Improving access to healthcare and identification of cost-effective approaches for earlier detection, smoking cessation and pulmonary rehabilitation for people with COPD (our 3 areas of focus), are part of the WHO 4 global priorities for non-communicable diseases [2,3]. Substantial underdiagnosis of COPD (>1/2 of cases) contributes to delayed intervention and poor outcomes, and is more marked in LMIC where population and health professional awareness is low and use of spirometry limited [4]. Whilst smoking is the main risk factor for disease onset and progression, passive smoking, occupational, indoor & outdoor air pollution exposures are additional contributors, particularly in LMICs [4]. LMIC PARTNERS COPD is one of the 10 leading causes of yrs of life lost in the 4 LMIC partners in this proposal (Brazil, Georgia, Macedonia, China)[5] and all have identified diagnosis and management of COPD as an unmet need. Partners were selected from the International Primary Care Respiratory Group (IPCRG) network, representing LMICs with different populations, varying risk exposures, and healthcare systems. The primary healthcare systems in all settings are still in development, none are actively tackling underdiagnosis and implementation of effective approaches for management of COPD, including delivery of smoking cessation services, are limited. Initial discussion with experts in our partner countries suggests low awareness and adherence to international guidelines for the diagnosis & management are driven by lack of training, the high cost of pharmacological treatments and limited experience and delivery of effective lower cost behavioural interventions. Research is very limited; & mainly in hospitals. AIMS & OBJECTIVES Through the strengthening of relationships with specific countries & supporting development of their research capacity, we propose to undertake community-based research to improve the identification and management of COPD patients, focusing on the poorest communities. This will contribute to better quality of life and reduction in the burden of COPD globally. In consultation with our partner collaborators, we have agreed these objectives: 1. Develop & consolidate a sustainable collaboration and shared vision between the UoB COPD research team (providing oversight, research method design and training), lead community respiratory researchers in Brazil, China, Georgia and Macedonia (responsible for conduct and delivery of agreed research projects & linking with policy makers to embed findings into local services) & the IPCRG (facilitating collaboration and dissemination through hosting of website, international meetings and liaising with other countries through their established network) 2. Co-create a local plan in each setting for evaluating approaches for identifying undiagnosed COPD in the community, adapted to cultural needs & the local healthcare infrastructure 3. Using the MRC framework for complex interventions to develop and test the feasibility of behavioural interventions aimed at the management of COPD patients in the community, focussing on our areas of expertise (treating tobacco dependence, promoting physical activity and self-management) 4. Building on the experiences gained and findings from the initial studies, to obtain funding for further research to reduce the burden of COPD worldwide. DEVELOPMENT OF RESEARCH PROJECTS We have started consultation with the leads for each partner country to gain understanding of their healthcare systems, burden and current management of COPD, priority research needs and likely training requirements. We have agreed 3 broad research themes related to our existing expertise. Within each theme preliminary research projects will focus on development of new – or adaptation of known effective – interventions, including: THEME 1: CASE-FINDING FOR UNDIAGNOSED COPD • Adaptation and evaluation of case finding tools (questionnaires, hand-held spirometers) to local settings in Georgia • Feasibility of case finding in different settings (eg in smoking cessation clinics in Brazil & Macedonia, using lay-health workers in Brazil, or as part of elderly health checks in China) THEME 2: PROMOTION OF SMOKING CESSATION IN THE COMMUNITY • Effect of spirometry screening, lung age/diagnosis of COPD on smoking cessation rates in Brazil and China • Identifying COPD patients’ views about various low-cost approaches to promote quitting (eg use of e-cigarettes, e-technology (eg text messaging)) • Feasibility of different models of delivering smoking cessation services in low resource settings THEME 3: BEHAVIOURAL INTERVENTIONS TO IMPROVE DISEASE MANAGEMENT • Adaptation and feasibility of providing pulmonary rehabilitation services in low resource settings, including exploring views of patients, healthcare professionals, policy makers • Exploration of the views of COPD patients on physical activity interventions • Feasibility of using e-technology to deliver pulmonary rehabilitation We will facilitate the prioritisation of 1-2 projects in each partner country. Each partner will consult with local policy-makers, healthcare professionals, patients to consider different dimensions (fit with local policy goals, perceived importance among local COPD patients & clinicians, logistic complexity of delivery, technical feasibility, available resources). Findings will be presented (eg as a star diagram) and a final decision made in consultation with all co-applicants and input from the international advisory group. Most projects will be mixed methods (quantitative & qualitative) and include a health economic element (eg measurement of resource use). DEVELOPMENT OF PARTNERSHIPS & STRENGTHENING CAPACITY Partnerships and mutual learning will be developed by holding an initial meeting to develop a shared vision followed by quarterly teleconference & annual face-to-face meetings, and ad-hoc email contact between partners. The UoB brings skills in study design and COPD research; the partner collaborators bring expertise in implementing research projects and delivering respiratory care in their settings. The exchange of knowledge, ideas and staff will be mutually beneficial. Comparison of project findings across countries where possible will further enhance shared learning. 6 MONTH DELIVERABLES (See Gantt chart) • Prioritise research topics • Undertake training needs assessment • Refine projects and develop minimum 4 research protocols • Create outline training plan MEDIUM (1-2 year) AIMS & OBJECTIVES • Develop and deliver bespoke research training for each country • Commence and complete data collection for agreed projects • Development of further protocols as needed • Develop sustainable relationships with policy makers LONG-TERM(2-3 years) AIMS & OBJECTIVES • Final report and individual papers from each completed project • Raise profile & ensure implementation of any clinically and cost-effective services by involving relevant policymakers • Share lessons learned across projects and countries • Develop future funding applications led by partner countries and sustainability plans SUSTAINABILITY PLANS We will strengthen collaborations over the 3-yrs, engaging throughout and beyond with national policy makers. During the final months focus will be development/application of new funding awards (eg NIHR, MRC, IPCRG, other charities, local funding bodies in partner countries). Each partner is already a member of the IPCRG network, so there is a natural forum for sustaining the relationships; we will put a plan in place to work with the IPCRG to ensure continued development and the opportunity to expand into other member countries.

Lay abstract: Chronic obstructive pulmonary disease (COPD) is a long-term incapacitating respiratory condition, responsible for substantial ill health (4th leading cause of death worldwide). The main causes, including smoking and exposure to indoor/outdoor air pollution are more common in low & middle income countries (LMIC). Awareness of COPD is very low, including in the countries we will work with. Over half of people who have COPD do not know they have the condition and are not receiving treatment which could help them. Local community healthcare systems are in development and limited treatment is available, especially in poorer areas. Services to help smokers quit are patchy, inhaler medications are often too expensive and other forms of effective treatment eg education, support for physical activity and management of breathlessness rarely available. We have an established group in Birmingham who have successfully undertaken research to improve earlier identification & treatment of COPD patients in UK primary care. We now want to work with partner LMICs, to adapt and help them apply what we have learnt from our research experience to their settings. By adapting known effective treatments, or testing new ones, we can contribute to improving the lives of COPD patients worldwide. We will also learn how to adapt our approaches for other settings. We have established links with the International Primary Care Respiratory Group (IPCRG), a charity with >30 countries as members which aims to promote the improvement of treatment for patients with lung diseases worldwide, through education & research. Through their extensive networks and our existing links, we have engaged with 4 partner LMICs where COPD is a main cause of death, underdiagnosis is common and there is recognition of a need to improve the health of people with COPD. The countries (Georgia, FYR Macedonia, China, Brazil) have different populations, risk profiles and distinct healthcare systems & needs. Research is limited & mainly in hospitals. Together we are working on this programme. Initially we will all meet to facilitate collaboration, determine working methods, agree shared research topics around earlier identification and community based treatments for people with COPD & identify training needs. Partners will have prioritise and plan 1-2 research projects by consulting with local patients, healthcare professionals & policy-makers. Training will be designed and delivered, patients recruited and projects completed. The final months will be focussed on developing new research proposals to sustain the collaboration. Throughout we will be advised by a committee of international experts. We will raise the profile of COPD in the partner countries with their national policy-makers and healthcare professionals, during the award and beyond with strategic high-profile meetings (through existing links between partners & national decision-making bodies) and involving them directly in the research. The IPCRG will also facilitate dissemination at their conferences/their website With the creation of this Global-COPD research group, we will develop partnerships with specific LMICs to stimulate development of community-based research, and co-develop the capability, networks & platform to deliver effective research in the longer term with a view to expanding our collaboration to other LMICs in future. This will ultimately lead to improvement in the lives of COPD patients worldwide.

Research activity codes: 4.5 RESOURCES AND INFRASTRUCTURE (DETECTION);7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT)
Health categories: RESPIRATORY