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BJGP Open. 2019 Feb 20;3(1):bjgpopen18X101632. doi: 10.3399/bjgpopen18X101632. eCollection 2019 Apr.

Feasibility of delivering integrated COPD-asthma care at primary and secondary level public healthcare facilities in Pakistan: a process evaluation.

Author information

Chief Coordinating Professional, Association for Social Development, Islamabad, Pakistan.
Research Coordinator, Association for Social Development, Islamabad, Pakistan.
Professor of International Public Health, Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK.
Project Coordinator, Association for Social Development, Islamabad, Pakistan.
Lecturer, Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK.
Assistant Professor, Humanities and Social Sciences Department, Bahria University, Islamabad, Pakistan.
Provincial Manager, Non-Communicable Disease Control Program, Punjab, Pakistan.
Director, NCD & Mental Health, Directorate General of Health Services, Lahore, Pakistan.



In Pakistan,the estimated prevalence of chronic obstructive pulmonary disease (COPD) and asthma are 2.1% and 4.3% respectively, and existing care is grossly lacking both in coverage and quality. An integrated approach is recommended for delivering COPD and asthma care at public health facilities.


To understand how an integrated care package was experienced by care providers and patients, and to inform modifications prior to scaling up.

Design & setting:

The mixed-methods study was conducted as part of cluster randomised trials on integrated COPD and asthma care at 30 public health facilities.


The care practices were assessed by analysing the clinical records of n = 451 asthma and n = 313 COPD patients. Semi-structured interviews with service providers and patients were used to understand their care experiences. A framework approach was applied to analyse and interpret qualitative data.


Utilisation of public health facilities for chronic lung conditions was low, mainly because of the non-availability of inhalers. When diagnosed, around two-thirds (69%) of male and more than half (55%) of female patients had severe airway obstruction. The practice of prescribing inhalers differed between intervention and control arms. Patient non-adherence to follow-up visits remained a major treatment challenge (though attrition was lower and slower in the intervention arm). Around half of the male responders who smoked at baseline reported having quit smoking.


The integrated care of chronic lung conditions at public health facilities is feasible and leads to improved diagnosis and treatment in a low-income country setting. The authors recommend scaling of the intervention with continued implementation research, especially on improving patient adherence to treatment.


Asthma; COPD; Integrated care; mixed method research; public health facilities

Conflict of interest statement

The authors declare that no competing interests exist.

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