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Chronic respiratory disease often gets misinterpreted as an infection across the globe

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December 16, 2021

Wednesday, December 15th 2021, marks a special day as medical journal The Lancet Global Health published a new mixed-method study on mapping low-resource contexts to prepare for lung health interventions in four countries, conducted by the ‘FRESH AIR collaborators’. This international research group, led by the LUMC, found worryingly that chronic respiratory disease (CRD) often gets misinterpreted as an infection, especially as tuberculosis. The study found three themes to address that might prove pivotal for adequate implementation of interventions for CRD.


About 80 million people suffer from chronic obstructive pulmonary disease (COPD) globally and a further 300 million are affected by asthma. The greatest burden of CRD occurs in low-resource settings. Most studies have, however, focused on creating an evidence-base for treatments of CRD in high-resource settings. Little is known about the application of this evidence-base to low-resource settings, contextual risk factors, and barriers that hamper implementation.

FRESH AIR is a three-year Horizon 2020 research project that addresses the urgent need to prevent, diagnose and treat lung diseases in diverse low-resource settings. It consists of several studies conducted in Uganda, Kyrgyzstan, Vietnam and Greece. The overall aim is to improve health outcomes by developing capacity for implementation of evidence-based interventions in these contexts.

This FRESH AIR study and its findings

Effectiveness of health programmes can be undermined when the implementation misaligns with local beliefs and behaviours. For the current study, the group explored beliefs and behaviours regarding CRD in aforementioned low-resource settings with the aim to design context-driven implementation strategies for CRD interventions. 340 villagers and health professionals were interviewed and observed during the study. Additionally, a questionnaire was filled out by 1037 villagers and 204 health professionals. Uniquely, the exact same evidence-based approach was utilized in each of the countries.

The research surprisingly showed that in each of the studied countries, the exact same three themes play a key role in CRD related beliefs and behaviours. Firstly, identification of the disease is an important theme. In these low-resource settings, apart from Greece, chronic diseases are rarely thought of and get mistaken for infections. Secondly, insight into causes of CRD or lacking. Even though smoking is considered a known risk, there is little to no attention to air pollution indoors (for instance by cooking on wood or dung, practices exercised by three billion people daily). Thirdly, the team found social norms and structures to determine CRD related behaviour, for instance in Kyrgyzstan and Vietnam, where ‘real men’ smoke.

Next steps

These themes are vital to address when implementing lung health programs in such settings. Previous studies have already shown that if healthcare programs misalign with social behaviours and convictions regarding disease, they are very likely to fail. This causes valuable resources to be wasted, which are already scarce in these settings. When designing context-driven implementation strategies for CRD-related interventions across these global settings, the three consistent themes should be addressed, each with common and context-specific beliefs and behaviours. Context-driven strategies can reduce the risk of implementation failure, thereby optimizing resource use to benefit health outcomes.

Read the article in The Lancet here.

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