FRESH AIR international research programme

Plymouth University is leading on several projects within the FRESH AIR programme including the pulmonary rehabilitation projects in remote settings, starting in mountain villages in Crete with aims to progress to remote high altitude nomadic communities in Kyrgyz Republic and rural communities in Vietnam.

There is also a project evaluating an education programme for midwives in rural Uganda to deliver improving pregnancy outcomes and child health in the first six months of life. The project teaches people about the dangers of biomass smoke from cooking fires, from kerosene lamps and other sources, including tobacco smoking. 

Dr Rupert Jones is leading a team of Plymouth researchers within an international collaboration in a range of studies addressing the problem of chronic lung disease in resource-poor settings.

Project one

Prevalence of chronic obstructive pulmonary disease and associated risk factors in Uganda (FRESH AIR Uganda): A prospective cross-sectional observational study


Complete and published in Lancet Global Health 2014.


In sub-Saharan Africa, little is known about the damage to respiratory health caused by biomass (wood, charcoal or grass) smoke and tobacco smoke. We assessed the prevalence of chronic obstructive pulmonary disease (COPD) and related risk factors in a rural region of Uganda.

We undertook a prospective observational cross-sectional study in rural Masindi, Uganda. We randomly selected people above the age of 30 years from 30 villages. We trained local health-care workers, asked validated questionnaires and administered breathing tests (spirometry) to participants. We defined COPD as FEV1:FVC less than the lower limit of normal. We calculated prevalence of COPD and tested its association with risk factors.

Between 13 April and 14 Aug 2012, we invited 620 people to participate, of whom 588 provided acceptable spirometry and were analysed.

  • mean age was 45 years; 297 (51 per cent) were women
  • 546 (93 per cent) were exposed to biomass smoke, many for all their lives
  • the prevalence of COPD was 16 per cent. Prevalence was highest in people aged 30 - 39 years
  • 44 per cent of men with COPD were current smokers, 24 per cent were former smokers
  • 8 per cent of women were current smokers, 18 per cent were former smokers
  • mean Clinical COPD Questionnaire score was 0·81, mean Medical Research Council dyspnoea score was 1·33; 30 per cent of 95 patients had had one or more exacerbations past 12 months
  • COPD was associated with wheeze and being a former smoker.



In this rural district of Uganda, COPD starts early in life. Major risk factors were biomass smoke for both sexes (but particularly in younger women) and tobacco smoke for men. In addition to high smoking prevalence in men, biomass smoke could be a major health threat to men and women in rural areas of Uganda.


International Primary Care Respiratory Group, Euro 150,000.


van Gemert F, Kirenga BJ, Chavannes N, Kamya M, Luzige S, Musinguzi P, Turyagaruka J, Jones R, Tsiligianni I, Williams S, de Jong C, van der Molen T. Prevalence of COPD in sub-Saharan Africa: FRESH AIR Uganda survey. Lancet Glob Health 2015; 3: e44–51

Project two

A development study to examine feasibility and acceptability of pulmonary rehabilitation in Uganda for adults with chronic respiratory disease

Chronic lung disease (CLD)

  • affects around one in five adults in Africa
  • arises from respiratory infections such as TB and HIV, tobacco smoking and nutritional impairment
  • patients with breathlessness related to CLD create damage to the economy through lost productivity and disability, and direct health service costs with frequent and prolonged hospital admissions
  • people with CLD are prone to breathlessness, inactivity, de-conditioning, declining health status and prognosis
  • CLDs are disproportionately prevalent in deprived populations and many sufferers can neither afford the drugs nor transport to medical clinics.

While medication may improve lung function and symptoms in some patients, for those with irreversible damage pulmonary rehabilitation (PR) is the only treatment and can be very effective. PR is a programme of exercise, education and self-management. PR involves existing local resources such as nurses, doctors, physiotherapists and clinic staff. PR allows patients to help each other and themselves, without major capital outlay or equipment.

We are running a development project in which we set up and ran a PR programme in Mulago Hospital, Kampala. A multidisciplinary team of doctors, nurses, physiotherapists and others have run five groups with around 40 patients with chronic lung damage secondary to pulmonary TB. Preliminary results confirm that the programme is feasible and acceptable to patients and to the hospital staff at all levels. Major improvements were seen in exercise capacity and health status. In many patients the experience was life changing, allowing severely incapacitated patients who were entirely dependent on others to now function normally in work and social activities.

The objective of the development project is to develop PR to a point where it may be deployed widely in East Africa and assessed in a large trial.


MRC Wellcome and DFID Joint Global Health Trials £162,880.69

The future

Our pilot study is showing that in small numbers of patients, unexpected improvements in chest pains, haemoptysis and night sweats occurred and this may open the door to research into physiotherapy approaches to post-TB morbidity, a subject receiving little attention in TB research and guidelines.

If the development study is successful we will progress to a major roll-out study through East Africa (Kenya, Tanzania and Zambia). The rehab programme is also an element within the Horizon 2020 funded programme of research – Fresh Air.

A patient's story (provided with consent)

"Two years ago our patient, an 18 year old woman, developed pulmonary TB. She became unwell with cough, fever, haemoptysis, breathlessness and weight loss. She had TB treatment but did not recover properly as she suffered with recurrent infection in cavitating lesions and was given repeated courses of antibiotics. These made little difference; she remained weak, tired, unable to attend school, very breathless, could only walk short distances and could not carry anything heavy."


"She had severe chest pains, especially at night. She became very depressed and worried for the future. Eventually she saw Dr WK in 2013, who referred her to the pulmonary rehabilitation programme and she attended throughout. She is now back to normal, attending school, and feels strong again "I have so strong muscles and bones". She has gained weight, her chest pains and haemoptysis have gone. She was so pleased that she came especially to thank me. She wants to be a doctor."

Project three

A project to develop awareness of lung health and promote practices to prevent lung disease in rural Uganda. The group will train community health workers (CHWs), create educational materials and utilise technology. Results and knowledge learned from the project will be shared in an effort to build capacity for stop smoking interventions in other low and middle income countries (LMICs). The IPCRG also plans to contribute data from the project to the body of evidence on the effectiveness of such interventions in LMICs.

Specifically, the project aims to:

1. Develop a cascading and sustainable ‘train the trainers’ module that will be used to train Masindi district community health workers (CHWs) and health care workers in improving lung health.

2. Create with CHWs educational materials that they can use with their local communities.

3. Train CHWs and health care workers in supporting people to stop using tobacco through interventions that are adapted to the local cultural and economic conditions and are feasible to implement in the context of Masindi District.

4. Provide on-going support to CHWs using mobile telephone technology.

5. Integrate these activities into a larger IPCRG supported programme to improve lung health.

6. Identify and share the learning from the project using the Global Bridges network and the IPCRG knowledge platform in order to build capacity for interventions that facilitate stopping tobacco use in other low and middle income countries (LMICs).

7. Contribute to developing the evidence-base on effectiveness and cost-effectiveness of interventions to facilitate stopping tobacco use in LMICs.


Project status update

We have exceeded our ambitions. The first training (TOT) had a target of training 10 health workers but trained 12. The second training had a target of training 50 health workers but trained 47. We aimed to train 50 village health teams, but will now train 600 to cover all 322 villages in Masindi District.

We have developed knowledge questionnaires and training materials.

The future

The training materials developed have been approved by the Ministry of Health and will be available for other areas and other projects. The VHTs will do a survey of houses in every village and report back to the District Medical Officer.

Wider communications are being developed, including radio adverts.

Project four

Free Respiratory Evaluation and Smoke-exposure reduction by primary Health cAre Integrated gRoups (FRESH AIR)

The overall aim of the FRESH AIR consortium and this project is to improve health outcomes for people at risk of or suffering from non-communicable lung diseases in low-resource settings. 

The project will achieve this through seven specific objectives.

1. To identify the specific factors that influence the implementation of evidenced-based interventions in the prevention and treatment of non-communicable lung diseases in community settings in four countries representing very different contexts: the Kyrgyz Republic, Vietnam, Uganda and Greece. (WP3)

2. To explore which awareness-raising approaches are most effective in motivating behaviour change in tobacco consumption and HAP exposure and to evaluate the feasibility, acceptability and effectiveness of HAP reduction interventions in selected communities in these countries. (WP4)

3. To provide access to smoking cessation support by adapting successful evidence-based Very Brief Advice (VBA) interventions that will be delivered by healthcare workers in these countries. (WP5)

4. To test the feasibility and acceptability of methods for diagnosing COPD using innovative spirometry. (WP5)

5. To test the feasibility and acceptability of pulmonary rehabilitation (PR) as a low-cost treatment for obstructive lung disease. (WP5)

6. To test how to best reduce children’s respiratory symptoms and the risk of lung damage by exploring interventions designed to raise awareness of the damaging effects of exposure to tobacco smoke and HAP during pregnancy and infancy and to improve diagnosis and treatment of children aged under-5 presenting to primary care with respiratory symptoms. (WP6)

7. To generate new knowledge, innovation and scalable models that ensure equitable access and to support their implementation through proactive dissemination within the four countries, regionally and internationally. (WP3 to WP7)

Project five

Fresh Air Uganda – Stakeholder interviews for the design and implementation of a project on lung health education programme with assessment of outcomes using M health – 2014–15

In January 2014 Dr Rupert Jones and Dr Frederik van Gemert visited Uganda for ten days to evaluate the possibility of running a Lung Health programme. 

They visited:

  • the respiratory department at Mulago Hospital and spoke to leading experts on lung disease, consultant physicians and the Head of Physiotherapist.
  • the Masindi district and spoke to local government officers including the chief and deputy chief ministers, the Health minister, the district health officer for Masindi and community health care workers at all clinical levels and the in the village health teams and villagers. 

More information can be found in our supplementary table

Interview structure

  • General comments on Lung Health and feasibility of Lung health Education initiative 
  • Written material (contents and presentation)
  • Biomass fuel smoke, other exposures
  • Communication systems 
  • Mobile phones / email / internet
The current use of mobile phones and practical applications of mobile phones by professional and unpaid community HCW workers and by people in the community

Summary of main themes

The proposed educational materials had been developed by the project team, and were in the format of a PowerPoint presentation. As the interviews were completed amendments were made and the presentation improved after almost every interview.

  • The contents – such as the need for a simple slide on what is COPD and one on COPD management. This is to include drugs, lifestyle changes and non-drug treatments.
  • The format – the main presentation could be in various formats including on a website or laptop computer, but for the educators written materials including A4 loose-leaf folders, posters and A3-sized flip charts are commonly used and have pictures to show the people with little or no text and more detailed information on reverse as an aid for the teachers.

General comments

There was some concern about COPD and that treatments in terms of drugs particularly inhalers were not available or affordable by local people, so they wondered if it was a priority. We explained that COPD can be prevented and managed by non-drug treatments and used the pulmonary rehabilitation programme as an example of how things can be made so much better without the use of expensive drugs. This message was new to them and well received.


There was uniform support for the project as being feasible and clear offers to facilitate the implementation of the project from the Government and the District Medical Officer. Likewise there was strong message from health care workers at all levels that a Lung Health education programme was important, necessary and feasible. Those involved with patient contact stated they would be happy to use the materials in their work. The HCWs confirmed that this were the right way to build on success of the Fresh Air Uganda project. The importance of communication was emphasised especially with the line of communications extending from Europe to Kampala to the Masindi province and down the chains of commands to the village health teams.

Biomass fuel exposure 

There was variable knowledge of the risks of biomass smoke to human lungs, some villagers were aware and were taking action in terms of cooking stoves, some were aware and taking no action, in one health centre (HC3) not one of the five HCWs were aware of biomass fuels causing lung damage. One nurse reported that villagers deliberately burn the branches of coniferous trees to create smoke in their house to repel insects. 

The exposure to biomass fuels was ubiquitous and started in utero and ends at death. Women and small children were particularly at risk. Cooking was traditionally done on a three stone method mainly inside huts, but there was interest in developing different ways of cooking because of fuel shortages and to reduce smoke exposure. Wood was the main form of fuel and charcoal was relatively expensive.

The villagers had to walk further to find wood and there are less and less trees in many areas. This was particularly problematic where intensive agriculture has reduced tree numbers, such as in the sugar plantation areas. For this reason there was interest in energy efficient stoves.

Some initiatives have been performed in the district and several villages had stoves with chimneys, but the vast majority did not. Retained heat cooking was generally a new concept to the interviewees and there was substantial interest on the basis if it advantages in reducing the wood burned and reducing smoke and risks of burns and hut fires. Some had heard about of retained heat cooking and reported positively. In the sugar cane areas where trees were short and people were out at work a lot the idea was especially interesting. There were requests for demonstrations before many would be convinced.

Other exposures

Cigarette use was not discussed in detail in this project as the Fresh Air Masindi project had provided extensive detailed information on its use. However, there was support for smoking cessation initiatives, including reducing passive exposure which was seen as a bad problem. In the sugar cane plantations the migrant workers were reported to smoke a great deal of cannabis. 

Occupational exposures were reported as a major problem for men, there was widespread and prolonged exposure, with little information about the risks. There was an absence of initiatives on protecting workers either from employers or form the Government. Few steps were taken to educate or even simple measure taken to reduce risk for example by increasing ventilation.

M Health project

Mobile phones were regularly used by all HCWs and would provide a good way to communicate about the project. There was generally good signal coverage and few technical problems in the use for telephone calls and SMS. The use of SMS text messages to provide standard updates and reminders would be helpful. They can also be used to liaise directly with project leaders. As 95 per cent of the local population have access to mobile phones and may be used to provide communication within the project team, and to contact local people.

Pulmonary rehabilitation in Uganda

The preceding pilot study and this film were funded by the International Primary Care Respiratory Group.