Cognitive mapping: using local knowledge for planning health research

Contextual awareness, response and evaluation (CARE) of diabetes in poor urban communities in Ghana: the CARE diabetes project qualitative study protocol

Diabetes remains a major, global clinical and public health threat with consistent rises in prevalence around the world over the past four decades. Two-thirds of the projected increases in global diabetes prevalence to 2045 are expected to come from low- and middle-income countries, including those in sub-Saharan Africa. Ghana is typical of this trend. However, there are gaps in evidence regarding the appropriate development of interventions and well-targeted policies for diabetes prevention and treatment that pay due attention to relevant local conditions and influences. Due consideration to community perspectives of environmental influences on the causes of diabetes, access to appropriate health services and care seeking for diabetes prevention and management is warranted, especially in urban settings. The 'Contextual Awareness, Response and Evaluation (CARE): Diabetes in Ghana' project is a mixed methods study in Ga Mashie, Accra. An epidemiological survey is described elsewhere. Six qualitative studies utilising a range of methodologies are proposed in this protocol to generate a contextual understanding of type 2 diabetes mellitus in an urban poor population. They focus on community, care provider, and policy stakeholder perspectives with a focus on food markets and environmental influences, the demand and supply of health services, and the history of the Ga Mashie community and its inhabitants. The results will be shared with the community in Ga Mashie and with health policy stakeholders in Ghana and other settings where the findings may be usefully transferable for the development of community-based interventions for diabetes prevention and control.

Adopting a systems-thinking approach to optimise dietary and exercise referral practices for cancer survivors

PURPOSE

Service referrals are required for cancer survivors to access specialist dietary and exercise support. Many system-level factors influence referral practices within the healthcare system. Hence, the aim of this study was to identify system-level factors and their interconnectedness, as well as strategies for optimising dietary and exercise referral practices in Australia.

METHODS

A full-day workshop involving national multidisciplinary key stakeholders explored system-level factors impacting dietary and exercise referral practices. Facilitated group discussions using the nominal group technique identified barriers and facilitators to referral practices based on the six World Health Organisation (WHO) building blocks. The systems-thinking approach generated six cognitive maps, each representing a building block. A causal loop diagram was developed to visualise factors that influence referral practices. Additionally, each group identified their top five strategies by leveraging facilitators and addressing barriers relevant to their WHO building block.

RESULTS

Twenty-seven stakeholders participated in the workshop, including consumers (n = 2), cancer specialists (n = 4), nursing (n = 6) and allied health professionals (n = 10), and researchers, representatives of peak bodies, not-for-profit organisations, and government agencies (n = 5). Common system-level factors impacting on referral practices included funding, accessibility, knowledge and education, workforce capacity, and infrastructure. Fifteen system-level strategies were identified to improve referral practices.

CONCLUSION

This study identified system-level factors and strategies that can be applied to policy planning and practice in Australia.

Future directions in human mobility science

We provide a brief review of human mobility science and present three key areas where we expect to see substantial advancements. We start from the mind and discuss the need to better understand how spatial cognition shapes mobility patterns. We then move to societies and argue the importance of better understanding new forms of transportation. We conclude by discussing how algorithms shape mobility behavior and provide useful tools for modelers. Finally, we discuss how progress on these research directions may help us address some of the challenges our society faces today.

Narrative sexual histories and perceptions of HIV risk among young women taking PrEP in southern Africa: Findings from a novel participatory method

Pre-exposure prophylaxis (PrEP) is an important HIV prevention method for adolescent girls and young women (AGYW) in Africa, who are at heightened risk of HIV infection. HIV risk perception is generally a powerful motivator for adoption of HIV prevention behaviours, including PrEP use. While HIV risk perceptions have been evaluated using quantitative measures, these seldom capture how individuals conceptualize and understand risk within local frameworks of meaning. More nuanced understanding may come from qualitative approaches that map these perceptions across the trajectory of sexual histories. Between 2016 and 2018, we implemented a novel participatory method to investigate risk perceptions in interviews with 32 participants in HPTN 082, a study of AGYW's use of PrEP in South Africa and Zimbabwe. Timelines were used to record narrative sexual histories and perceived HIV risk for each relationship. We found that women assessed HIV risk primarily based on their partners' personal qualities and behaviour (especially relating to infidelity); their subjective experience of being treated respectfully; and the practice of perceived 'risk reduction', including younger partners and condoms, even if used inconsistently. A narrative timeline approach grounded in an understanding of young women's sexual histories may increase critical reflection about HIV risks and facilitate risk-reduction counselling with this group.

COGNITIVE MAPPING FOR ILOOKOUT FOR CHILD ABUSE: AN ONLINE TRAINING PROGRAM FOR EARLY CHILDHOOD PROFESSIONALS

This article delineates the theory and framework for an innovative child abuse training program for mandated reporters called 'iLookOut'. iLookOut is an online learning delivery system that utilizes mastery learning and self-determination theory in the Core Training program, along with spaced retrieval and retrieval practice in a follow-up micro-learning program that reinforces learning from the Core Training. A cognitive mapping model provides the structure for documenting and organizing the learning content in both the Core training and the follow-up micro-learning program. The article provides a conceptual framework for designing and implementing effective and efficient online learning programs.

Tygerberg Research Ubuntu-Inspired Community Engagement Model: Integrating Community Engagement into Genomic Biobanking

Introduction: Community engagement (CE) is an ethical imperative in research, but the knowledge base for what constitutes effective and ethically sound CE is limited. Ubuntu, as a component of responsive communitarianism where communal welfare is valued together with individual autonomy, is useful in furthering our understanding of effective CE and how it could best be achieved. Similarly, a relative solidarity model serves as a compromise between extreme individualism and extreme communalism and is more appropriate in a heterogenous African context. Approaching CE from an Ubuntu philosophical perspective in southern Africa is particularly important in genomic biobanking, given the implications for individuals, families, and communities.

Discussion: CE is often implemented in a tokenistic manner as an ancillary component of research. Understanding consent information is challenging where genomic biobanking is concerned due to scientific complexity. We started a process of CE around genomic biobanking and conducted empirical research in an attempt to develop a model to promote effective and ethically sound CE, using relative solidarity to create a nuanced application of Ubuntu. The TRUCE model is an eight-step model that uses social mapping to identify potential communities, establishes the scope of CE, and requires that communities are approached early. Co-creation strategies for CE are encouraged and co-ownership of knowledge production is emphasized. Recruiting and engaging communities at each stage of research is necessary. Evaluation and adaptation of CE strategies are included. Discussion and dissemination of results after the research is completed are encouraged.

Conclusions: There is a significant gap between the theory of CE and its authentic application to research in Africa. This Ubuntu-inspired model facilitates bridging that gap and is particularly suited to genomic biobanking. The CE model enhances and complements the consent process and should be integrated into research as a funding and regulatory requirement where applicable.

Forming and implementing community advisory boards in low- and middle-income countries: a scoping review

BACKGROUND

Community advisory boards (CABs) have expanded beyond high-income countries (HICs) and play an increasing role in low- and middle-income country (LMIC) research. Much research has examined CABs in HICs, but less is known about CABs in LMICs. The purposes of this scoping review are to examine the creation and implementation of CABs in LMICs, including identifying frequently reported challenges, and to discuss implications for research ethics.

METHODS

We searched five databases (PubMed, Embase, Global Health, Scopus, and Google Scholar) for publications describing or evaluating CABs in LMICs. Two researchers independently reviewed articles for inclusion. Data related to the following aspects of CABs were extracted from included publications: time, country, financial support, research focus, responsibilities, and challenges. Thematic analyses were used to summarize textual data describing challenges.

RESULTS

Our search yielded 2005 citations, 83 of which were deemed eligible for inclusion. Most studies (65) were published between 2010 and 2017. Upper-middle-income countries were more likely to have studies describing CABs, with South Africa (17), China (8), and Thailand (7) having the greatest numbers. The United States National Institutes of Health was the main source of financial support for CABs. Many CABs (53/88, 60%) focused on HIV research. Thirty-four studies reported how CABs influenced the informed consent process for clinical trials or other aspects of research ethics. CAB responsibilities were related to clinical trials, including reviewing study protocols, educating local communities about research activities, and promoting the ethical conduct of research. Challenges faced by CABs included the following: incomplete ethical regulations and guidance; limited knowledge of science among members of communities and CABs; unstable and unbalanced power relationships between researchers and local communities; poor CAB management, including lack of formal participation structures and absence of CAB leadership; competing demands for time that limited participation in CAB activities; and language barriers between research staff and community members. Several challenges reflected shortcomings within the research team.

CONCLUSIONS

Our findings examine the formation and implementation of CABs in LMICs and identify several ethical challenges. These findings suggest the need for further ethics training among CAB members and researchers in LMICs.

Emotional geographies of irregular transmigrants’ journeys

Migrants’ journeys involve geopolitical, corporeal, and emotional dimensions. Yet, emotions, which are fundamental to understand the migrant experience, are usually overlooked. Following the ‘emotional geographies’ approach, this article analyses the spatial contextualisation of the affective and emotional experiences of irregular migrants in transit. Cognitive mapping methodology is proposed as a means to address the spatial and subjective dimensions of migrants’ experiences. The ‘testimonial maps’ of two Central American transmigrants in Mexico are explored. The emotional geographies of irregular transmigration underscore the emotional turmoil associated with the irregular migratory process(es). They shed light to the familiar arrangements made before the journey, the natural landscape as part of the control, the encounters with agents of the state and criminal actors, the sanctuary places, the acquaintances and fortuitous friendships, the resilience and adaptability needed for endure the journey, and, beneath all this, the multi-emotional dimension of the journey: love, sorrow, shame, courage, anxiety, fear, trust, kindness, and hope.

Stakeholder engagement to inform HIV clinical trials: a systematic review of the evidence

INTRODUCTION

Stakeholder engagement is an essential component of HIV clinical trials. We define stakeholder engagement as an input by individuals or groups with an interest in HIV clinical trials to inform the design or conduct of said trials. Despite its value, stakeholder engagement to inform HIV clinical trials has not been rigorously examined. The purpose of our systematic review is to examine stakeholder engagement for HIV clinical trials and compare it to the recommendations of the UNAIDS/AVAC Good Participatory Practice (GPP) guidelines.

METHODS

We used the PRISMA checklist and identified English language studies describing stakeholder engagement to inform HIV clinical trials. Four databases (PubMed, Ovid, CINAHL and Web of Science) and six journals were searched, with additional studies identified using handsearching and expert input. Two independent reviewers examined citations, abstracts and full texts. Data were extracted on country, engagement methods, stakeholder types and purpose of stakeholder engagement. Based on the GPP guidelines, we examined how frequently stakeholder engagement was conducted to inform clinical trial research question development, protocol development, recruitment, enrolment, follow-up, results and dissemination.

RESULTS AND DISCUSSION

Of the 917 citations identified, 108 studies were included in the analysis. Forty-eight studies (44.4%) described stakeholder engagement in high-income countries, thirty (27.8%) in middle-income countries and nine (8.3%) in low-income countries. Fourteen methods for stakeholder engagement were identified, including individual (e.g. interviews) and group (e.g. community advisory boards) strategies. Thirty-five types of stakeholders were engaged, with approximately half of the studies (60; 55.6%) engaging HIV-affected community stakeholders (e.g. people living with HIV, at-risk or related populations of interest). We observed greater frequency of stakeholder engagement to inform protocol development (49 studies; 45.4%) and trial recruitment (47 studies; 43.5%). Fewer studies described stakeholder engagement to inform post-trial processes related to trial results (3; 2.8%) and dissemination (11; 10.2%).

CONCLUSIONS

Our findings identify important directions for future stakeholder engagement research and suggestions for policy. Most notably, we found that stakeholder engagement was more frequently conducted to inform early stages of HIV clinical trials compared to later stages. In order to meet recommendations established in the GPP guidelines, greater stakeholder engagement across all clinical trial stages is needed.

Collateral benefits: how the practical application of Good Participatory Practice can strengthen HIV research in sub-Saharan Africa

INTRODUCTION

The Good Participatory Practice (GPP): Guidelines for Biomedical HIV Prevention Trials, second edition (2011) were developed to provide clinical trial sponsors and implementers with a formal stakeholder engagement framework. As one of the largest African research institutes, Wits Reproductive Health and HIV Institute (Wits RHI) became an early adopter of GPP by implementing its principles within large-scale national and regional clinical trials. This article examines Wits RHI's lessons learned from implementing GPP, its ongoing efforts to institutionalize GPP, and the yet to be realized potential in creating fully sustainable structures for meaningful stakeholder engagement in HIV prevention research, implementation science and beyond.

DISCUSSION

For the past seven years, Wits RHI has undertaken both centralized leadership roles in implementing GPP across multi-party regional research consortia as well as overseeing GPP for smaller investigator-driven trials. Through this iterative roll-out of GPP, key lessons have emerged. Obtaining upfront funding to support GPP activities throughout and between the research life cycle, and a trained multi-disciplinary team of GPP practitioners have helped facilitate an enabling environment for GPP implementation. We further recommend formally integrating stakeholder engagement into study documents, including monitoring and evaluation plans with indicators and performance metrics, to assist teams to track and refine their GPP strategies. Finally, institutionalizing resources and supporting organization-wide GPP along with ongoing support can help build efficiencies and maximize economies of scale toward a pragmatic and innovative application of the GPP Guidelines.

CONCLUSIONS

Thanks to a growing global network of GPP practitioners and a burgeoning GPP Community of Practice, there has been substantive progress in making GPP an integral component of clinical HIV prevention research. The Wits RHI experience highlights the possibilities and the challenges to translating the GPP principles into concrete practices within specific clinical trials and across a research institute. Realizing the full potential of GPP, including direct and indirect - 'collateral benefits' will require the collective buy-in and support from sponsors, implementers and community stakeholders across the research field. As the HIV prevention research field expands, however, a more conscious and systematic implementation of GPP is timely.

"Honey, Milk and Bile": a social history of Hillbrow, 1894-2016

This commentary constructs a social history of Hillbrow, an inner-city suburb in Johannesburg, South Africa, based on a review of relevant published historical, anthropological and sociological texts. We highlight the significant continuities in the social structure of the suburb, despite the radical transformations that have occurred over the last 120 years.

Originally envisaged as a healthy residential area, distinct from the industrial activity of early Johannesburg, Hillbrow was a prime location for health infrastructure to serve the city. By the late 1960s, the suburb had been transformed by the rapid construction of high rise office and apartment buildings, providing temporary low cost accommodation for young people, migrants and immigrants. In the 1980s, Hillbrow defied the apartheid state policy of racial separation of residential areas, and earned the reputation of a liberated zone of tolerance and inclusion. By the 1990s, affected by inner-city decay and the collapse of services for many apartment buildings, the suburb became associated with crime, sex work, and ungovernability. More recently, the revitalisation of the Hillbrow Health Precinct has created a more optimistic narrative of the suburb as a site for research and interventions that has the potential to have a positive impact on the health of its residents.

The concentration of innovative public health interventions in Hillbrow today, particularly in the high quality health services and multidisciplinary research of the Hillbrow Health Precinct, creates the possibility for renewal of this troubled inner-city suburb.

From fear to resilience: adolescents' experiences of violence in inner-city Johannesburg, South Africa

Background

For adolescents growing up in poor urban South African settings, violence is often a part of daily life and has lasting effects on physical and mental health outcomes in adulthood. We conducted a qualitative study to document and understand the forms of interpersonal violence experienced by adolescents living in Hillbrow, Johannesburg. In this article, we explore how violence is experienced differently by adolescent boys and girls, how they conceptualise ‘dangerous’ and ‘safe’ spaces in their neighbourhood and what gaps exist in available services for youth in Hillbrow.

Methods

The article draws on data collected in the formative phase of the ‘Wellbeing of Adolescents in Vulnerable Environments’ (WAVE) Study of challenges faced by adolescents (15–19 years) growing up in impoverished parts of five cities. This article reports on analysis using only data from the Johannesburg site. Using both purposive and snowball sampling to select participants, we conducted in-depth interviews (n = 20) and community mapping exercises with female (n = 19) and male (n = 20) adolescents living in Hillbrow, as well as key informant interviews with representatives of residential shelters, CBOs, and NGOs working with youth (n = 17). Transcripts were coded manually and analysed using an inductive thematic analysis approach.

Results

Both girls and boys reported high exposure to witnessing violence and crime. For girls, the threat of sexual harassment and violence was pervasive, while boys feared local gangs, the threat of physical violence, and being drawn into substance-abuse. Home was largely a safe haven for boys, whereas for girls it was often a space of sexual violence, abuse and neglect. Some adolescents developed coping mechanisms, such as actively seeking out community theatres, churches and other places of sanctuary from violence. Community-based services and shelters that support adolescents reported a lack of resources, overall instability and difficulties networking effectively.

Conclusions

Adolescents in Hillbrow commonly witnessed and had direct experience of many forms of violence in their environment, and these experiences differed markedly by gender. Interventions that build young peoples’ social capital and resilience are essential for reducing violence-related trauma and long-term health and social consequences for adolescents in this community.

Adherence and the Lie in a HIV Prevention Clinical Trial

The lie has been presented as a performance that protects identities against moral judgment in the context of power imbalances. We explore this assertion from the perspective of a pre-exposure prophylaxis trial to prevent HIV for African women in South Africa, in which context biological evidence of widespread lying about product adherence was produced, resulting in a moral discourse that opposed altruistic and selfish motivations. In this article, we seek to understand the meaning of the lie from the perspective of women trial participants. Seeing the trial as representing a hopeful future, and perfect adherence as sustaining their investment in this, participants recited scripted accounts of adherence and performed the role of the perfect adherer, while identifying other participants as dishonest. Given that clinical trials create moral orders and adherence is key to this, we argue that women embraced the apparatus of the clinical trial to assert their moral subjectivities.

Community engagement strategies for genomic studies in Africa: a review of the literature

BACKGROUND

Community engagement has been recognised as an important aspect of the ethical conduct of biomedical research, especially when research is focused on ethnically or culturally distinct populations. While this is a generally accepted tenet of biomedical research, it is unclear what components are necessary for effective community engagement, particularly in the context of genomic research in Africa.

METHODS

We conducted a review of the published literature to identify the community engagement strategies that can support the successful implementation of genomic studies in Africa. Our search strategy involved using online databases, Pubmed (National Library of Medicine), Medline and Google scholar. Search terms included a combination of the following: community engagement, community advisory boards, community consultation, community participation, effectiveness, genetic and genomic research, Africa, developing countries.

RESULTS

A total of 44 articles and 1 thesis were retrieved of which 38 met the selection criteria. Of these, 21 were primary studies on community engagement, while the rest were secondary reports on community engagement efforts in biomedical research studies. 34 related to biomedical research generally, while 4 were specific to genetic and genomic research in Africa.

CONCLUSION

We concluded that there were several community engagement strategies that could support genomic studies in Africa. While many of the strategies could support the early stages of a research project such as the recruitment of research participants, further research is needed to identify effective strategies to engage research participants and their communities beyond the participant recruitment stage. Research is also needed to address how the views of local communities should be incorporated into future uses of human biological samples. Finally, studies evaluating the impact of CE on genetic research are lacking. Systematic evaluation of CE strategies is essential to determine the most effective models of CE for genetic and genomic research conducted in African settings.