Non-communicable lung disease in Kenya: from burden and early life determinants to participatory inter-disciplinary solutions

The lung diseases asthma and chronic obstructive pulmonary disease (COPD) are very common. Around the world 300 million people have asthma and 200 million have COPD. Low- to middle-income countries (LMICs) such as Kenya shoulder the burden of asthma and COPD. These diseases interfere with the lives of people, they stop people working and cost them money. The diseases also hold back countries from developing. The Kenyan Government has highlighted asthma and COPD as national priorities. Research from high income countries shows that the process of developing asthma and COPD starts early in life when we are children, or even earlier. Although research has shown that many adults in Africa have reduced lung function, no one has looked to see if this starts early in life.

Our team of researchers and doctors from Kenya and the UK will work closely with two communities in Nairobi, Kenya, to design and carry out a project looking into the early life origins of lung disease. We are interested in what causes lung disease and how people experience lung disease. We want to find out how early these diseases start, so that eventually we can prevent lung diseases by targeting the right age groups.

Our focus is on children and young adults aged 5 to 18 years because this is the age at which lungs are developing, and ill-effects at this time of life can impact the rest of people's lives. We will work in two areas: an informal settlement (Mukuru) and a wealthier area (Bura Bura). These two areas are geographically very close but very different in terms of their socio-economic make up. We will involve community members in all stages of the scientific process (including bid-writing, design, data collection, communication and project evaluation). We want to do this because it ensures that our research is directly relevant to community members and the results are more likely to be acted upon. We are particularly interested to look at the effects of indoor and outdoor air pollution, birth weight and early life chest infections.

We will conduct a survey of children/young adults aged 5-18 years - 1000 in Mukuru and 1000 in Bura Bura. The children and young adults will be recruited through local schools. The parents of the young people who want to take part will be visited by local field workers. The field workers will ask questions about lung symptoms, sources of indoor air pollution and any known lung problems. We will ask mothers if we can look at the Child Health Card that records birth weight, childhood weights and chest infections. We will measure the lung function of the young people using a simple blowing test called spirometry. We will do this before and after they run for 6 minutes, a simple way of looking for a form of asthma. To look at the effect of air pollution we will measure the air pollution experienced for a day by 100 young people from each community. They will be asked if they would wear a bag with some light-weight monitoring equipment for a day. The results of this monitoring will be used with the questionnaires to estimate exposure to air pollution for all those taking part.

The information gathered will be used to see if more children than expected have reduced lung function and at what age this appears. We will also see if air pollution, birth weight and early life chest infections affect the lung function of children. This has never been done before in Africa. The study is large enough to make fairly precise estimates of prevalence and to look for associations.

The results of this study will be fed back to the two communities in easily understandable ways, including theatre and comics. We will also let scientists, doctors and those interested in lung disease know the findings of the study. Although this study will not provide definitive proof, it is the first step for showing that lung diseases in Africa start early in life and can be prevented by targeting the right age group.

The Kenya National Strategy for non-communicable diseases highlights the impact of the non-communicable lung diseases asthma and chronic obstructive pulmonary disease (COPD) and makes their prevention and control national priorities. Studies in Africa reveal a high prevalence of COPD in adults unattributable to smoking. It is generally accepted that COPD in Africa is driven by pollution from biomass fuels, however the evidence is conflicting. Consensus in high income countries is that asthma and COPD originate in early life, being manifestations of reduced childhood lung function tracking into later life. It remains to be seen in Africa whether reduced adult lung function is a consequence of tracking of reduced childhood lung function and if so which factors reduce childhood lung function.

We propose a cross sectional survey in two communities in Nairobi, Kenya. 1000 children aged 5-18years will be studied in the informal settlement of Mukuru and 1000 in the adjacent affluent Bura Bura. We will investigate whether air pollution, low birth weight and early life respiratory tract infections are adversely associated with lung function in children whose lungs are developing and highly vulnerable to environmental insults. Novel participatory methods will embed the study in the communities in order to give communities ownership and say over design, conduct and dissemination. Fieldworkers will administer questionnaires for respiratory symptoms, demographics, indoor/outdoor air pollution sources. Birth weight, and respiratory tract infections will be obtained from Child Health Cards. Spirometry will be conducted before and after a 6 minute run. In 100 children from each community, 24 hour personal air quality monitoring will be conducted. Pollution exposures for all children will be modelled. We anticipate this study will demonstrate that a substantial proportion of African children have reduced lung function, the age this is first evident and associated risk factors.

Ultimately, our interdisciplinary research approach is co-produced with the communities we are working in to ensure that the research delivers on improved respiratory health and wellbeing, in line with the Kenya National Strategy for the Prevention and Control of Non-Communicable Diseases. Improved health will lead to greater economic prosperity for residents through increased capacity for pursuing education and undertaking paid work (fewer sick days, reduced need to care for sick dependents). We have developed this proposal because the existing projects being undertaken in these communities have highlighted the public demand for robust and scientific evidence of respiratory health in Mukuru and Buruburu (e.g. at the January 2018 AIR Network workshop in Mukuru). In the short-term the non-academic beneficiaries of this research will include the 2000 study participants and their parents, the sub-sample of 200 participants who take citizen scientist roles and measure their exposure to air pollution, the community members in Mukuru and Buruburu who are trained as research assistants to collect questionnaire data, the Community Advisory Board, the residents of two urban Kenyan communities more widely, community health workers (e.g. at Reuben Health Clinic), civil society organisations [CSO] (e.g. Muungano wa Wanavijiji, the faith-based Reuben Centre, Kenya Medical Association and Kenya Alliance of Residents Associations), local industries and local policy makers (e.g. Nairobi City County government who have designated Mukuru as a Special Planning Area [SPA], the Kenyan Ministry of Health and the Kenya Air Quality Network). In the longer-term the developed participatory approach is scalable and can be applied to other communities across Africa and beyond. The lung health burden evidence base generated in this project will be used as the basis for the development of co-produced interventions that are firmly rooted in the local cultural context and are therefore more likely to yield health improvements. Community residents are at the heart of this project, and community members have already been and will continue to be involved in the research design, formulation of research questions, development of methods, data collection and dissemination of findings. This is possible because of the trustful relationships that already exist between our researchers and community members based on ongoing projects in these communities (e.g. the AIR network). This will increase community trust (of researchers, in data), problem ownership, and acceptance of study findings. By involving community members at all stages of the research process, we will undertake research that delivers for them. By the end of the project community members will have an accessible evidence base with which to advocate for multi-level changes (e.g. policy) to improve their lung health. In addition, community capacity will be enhanced through training of community members as research assistants, social cohesion further strengthened as community members unite over a shared issue and residents who are frequently excluded from decision making processes that impact their everyday lives will be given greater voice (e.g. through the creation of discussion forums via workshops with local industry, policy makers and other stakeholders). Policy makers and CSOs will benefit from a robust evidence base of non-communicable lung diseases in Nairobi, as well as engagement with residents that experience the burden of disease and understanding community health needs and aspirations. Mukuru's designation as a SPA by the Nairobi City County government offers a unique opportunity for findings to feed into the Mukuru Integrated Development Plan. More widely, the project has the opportunity to contribute to city-level development agendas including the Kenya Vision 2030 and the Urban Development Nairobi Master Plan.