How might global health master deadly sins and strive for greater virtues?

The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial

Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster randomized contolled trial (RCT) took place in five Tanzanian hospitals. Hospitals were randomized to receive immediate (Group 1; n = 11 483 participants) or delayed (Group 2; n = 8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n = 9786) or unexposed (n = 10 145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was 7% points higher among the exposed (95% confidence interal (CI): 0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI: 0.10, 2.34). The likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on an IUD alone was 14% points higher among the exposed (95% CI: 0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health programme planning and implementation.

'Vulnerable' but not 'Valuable': Older refugees and perceptions of deservingness in medical humanitarianism

In a crisis, there is widespread recognition and acceptance that not all lives can be saved. But whose lives can legitimately be saved and who decides? Recent scholarship has begun to examine how refugees perceived as 'vulnerable', such as women and children, are frequently prioritized over other groups in humanitarian responses. Such analyses, however, fail to adequately explain why some groups - such as older persons - are considered vulnerable and yet are largely neglected. Based on the case of older Syrian refugees in Jordan, this article critically examines the ways in which humanitarian health actors make sense of the humanitarian principle of 'impartiality' in the face of limited resources. Based on 61 interviews and observational data collected in Jordan between 2017 and 2019, my results show that humanitarians routinely classify older refugees as 'vulnerable' and in need of medical assistance. Yet I find that three neoliberal considerations - including perceptions of the reduced lifespan, disproportionate disease burden, and limited contributions to the economy of older refugees - make this demographic low 'value for money'. This article expands our understanding of how medical humanitarian understandings of 'deservingness' are increasingly shaped by market-driven logics, and how these (re)create ageist, gendered and racialized hierarchies within refugee health.

Programmatic norms change to eliminate violence against children: Insights for practitioners and researchers from a UNICEF global mapping study

Interest in gender norms is rising within the field of global health and among its funders. With more resources available for norms change work, international institutions seek to develop thoughtful strategic and programmatic responses to a variety of issues, including violence against children. Yet changing deeply rooted gender norms requires sensitivity to local context. This can present a challenge for mid- to large sized organisations, as well as funders, who are typically required to develop strategies that encompass multiple contexts. This paper presents practical lessons learned from a mapping study of UNICEF's existing work to change discriminatory gender norms. As the world's leading children's rights organisation, preventing violence against children (0-9) and adolescents (ages 10-19) is a key component of UNICEF's work. This mapping formed the foundation of the institution's efforts to build out a coordinated strategy and programme of work around 'positive gender socialisation.' The mapping was unique in that it accounted for differences across and within regions and sought to develop an institutional programme of work based on local experience and existing priorities. The lessons learned are relevant to other organisations and practice-oriented research programmes embarking on work to change norms that lead to violence against children.

Using natural experimental studies to guide public health action: turning the evidence-based medicine paradigm on its head

Despite smaller effect sizes, interventions delivered at population level to prevent non-communicable diseases generally have greater reach, impact and equity than those delivered to high-risk groups. Nevertheless, how to shift population behaviour patterns in this way remains one of the greatest uncertainties for research and policy. Evidence about behaviour change interventions that are easier to evaluate tends to overshadow that for population-wide and system-wide approaches that generate and sustain healthier behaviours. Population health interventions are often implemented as natural experiments, which makes their evaluation more complex and unpredictable than a typical randomised controlled trial (RCT). We discuss the growing importance of evaluating natural experiments and their distinctive contribution to the evidence for public health policy. We contrast the established evidence-based practice pathway, in which RCTs generate 'definitive' evidence for particular interventions, with a practice-based evidence pathway in which evaluation can help adjust the compass bearing of existing policy. We propose that intervention studies should focus on reducing critical uncertainties, that non-randomised study designs should be embraced rather than tolerated and that a more nuanced approach to appraising the utility of diverse types of evidence is required. The complex evidence needed to guide public health action is not necessarily the same as that which is needed to provide an unbiased effect size estimate. The practice-based evidence pathway is neither inferior nor merely the best available when all else fails. It is often the only way to generate meaningful evidence to address critical questions about investing in population health interventions.

The technological imperative in tuberculosis care and prevention in Vietnam

A monocausal bacteriological understanding of infectious disease orients tuberculosis control efforts towards antimicrobial interventions. A bias towards technological solutions can leave multistranded public health and social interventions largely neglected. In the context of globalising biomedical approaches to infectious disease control, this ethnography-inspired review article reflects upon the implementation of rapid diagnostic technology in low- and middle-income countries. Fieldwork observations in Vietnam provided a stimulus for a critical review of the global rollout of tuberculosis diagnostic technology. To address local needs in tuberculosis control, health managers in resource-poor settings are readily cooperating with international donors to deploy novel diagnostic technologies throughout national tuberculosis programme facilities. Increasing investment in new diagnostic technologies is predicated on the supposition that these interventions will ameliorate disease outcomes. However, suboptimal treatment control persists even when accurate diagnostic technologies are available, suggesting that promotion of singular technological solutions can distract from addressing systemic change, without which disease susceptibility, propagation of infection, detection gaps, diagnostic delays, and treatment shortfalls persist.

The Data Hustle: How Beneficiaries Benefit from Continual Data Collection and Humanitarian Aid Research in the Somali Region of Ethiopia

Based on ethnographic and policy research in the Somali Region of Ethiopia, this article examines how contemporary trends in the humanitarian relief industry to mandate continual data collection, "accountability," and the "localization" of aid have increased demands for participatory and intensive research methodologies in crisis-affected communities. International humanitarian relief agencies hustle to hire local staffs and recruit enough participants for their repeated research projects, while at the same time, the so-called beneficiaries of aid also hustle to participate in data collection as paid informants and temporary employees. Research is an important side gig for many beneficiaries, and beneficiaries' regular participation is vital to reforming humanitarian practice. Beneficiaries are not therefore passive recipients of charity, but actively help produce the representations of crisis and suffering that, in turn, potentially qualify them for aid. Their indispensability and activity within contemporary humanitarian "audit cultures" therefore present emergent but limited forms of counter-hegemonic power.

Thirty-Six-Month Outcomes of a Generalist Paraprofessional Perinatal Home Visiting Intervention in South Africa on Maternal Health and Child Health and Development

Almost all pregnant women (98 %) in 24 Cape Town neighborhoods were randomized by neighborhood to (1) the standard care (SC) condition (n = 12 neighborhoods; n = 594 pregnant women) or (2) the Philani Intervention Program (PIP) in which home visits by Community Health Workers (CHW) were conducted (n = 12 neighborhoods; n = 644 pregnant women). At 36 months post-birth (84.6 % follow-up), PIP mothers were significantly less depressed compared to the SC mothers. Children in PIP were significantly less likely to be stunted (24.3 vs 18.1 %, p = 0.013), to have better vocabularies, and were less likely to be hospitalized than children in the SC condition. These data suggest home visits may need to continue for several years post-birth. Sustainable, scalable perinatal intervention models are needed in LMIC.

Research priority setting for integrated early child development and violence prevention (ECD+) in low and middle income countries: An expert opinion exercise

Child development in low and middle income countries (LMIC) is compromised by multiple risk factors. Reducing children's exposure to harmful events is essential for early childhood development (ECD). In particular, preventing violence against children - a highly prevalent risk factor that negatively affects optimal child development - should be an intervention priority. We used the Child Health and Nutrition Initiative (CHNRI) method for the setting of research priorities in integrated Early Childhood Development and violence prevention programs (ECD+). An expert group was identified and invited to systematically list and score research questions. A total of 186 stakeholders were asked to contribute five research questions each, and contributions were received from 81 respondents. These were subsequently evaluated using a set of five criteria: answerability; effectiveness; feasibility and/or affordability; applicability and impact; and equity. Of the 400 questions generated, a composite group of 50 were scored by 55 respondents. The highest scoring research questions related to the training of Community Health Workers (CHW's) to deliver ECD+ interventions effectively and whether ECD+ interventions could be integrated within existing delivery platforms such as HIV, nutrition or mental health platforms. The priority research questions can direct new research initiatives, mainly in focusing on the effectiveness of an ECD+ approach, as well as on service delivery questions. To the best of our knowledge, this is the first systematic exercise of its kind in the field of ECD+. The findings from this research priority setting exercise can help guide donors and other development actors towards funding priorities for important future research related to ECD and violence prevention.

Non-communicable disease syndemics: poverty, depression, and diabetes among low-income populations

The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.

Global Mental Health: Five Areas for Value-Driven Training Innovation

OBJECTIVE

In the field of global mental health, there is a need for identifying core values and competencies to guide training programs in professional practice as well as in academia. This paper presents the results of interdisciplinary discussions fostered during an annual meeting of the Society for the Study of Psychiatry and Culture to develop recommendations for value-driven innovation in global mental health training.

METHODS

Participants (n = 48), who registered for a dedicated workshop on global mental health training advertised in conference proceedings, included both established faculty and current students engaged in learning, practice, and research. They proffered recommendations in five areas of training curriculum: values, competencies, training experiences, resources, and evaluation.

RESULTS

Priority values included humility, ethical awareness of power differentials, collaborative action, and "deep accountability" when working in low-resource settings in low- and middle-income countries and high-income countries. Competencies included flexibility and tolerating ambiguity when working across diverse settings, the ability to systematically evaluate personal biases, historical and linguistic proficiency, and evaluation skills across a range of stakeholders. Training experiences included didactics, language training, self-awareness, and supervision in immersive activities related to professional or academic work. Resources included connections with diverse faculty such as social scientists and mentors in addition to medical practitioners, institutional commitment through protected time and funding, and sustainable collaborations with partners in low resource settings. Finally, evaluation skills built upon community-based participatory methods, 360-degree feedback from partners in low-resource settings, and observed structured clinical evaluations (OSCEs) with people of different cultural backgrounds.

CONCLUSIONS

Global mental health training, as envisioned in this workshop, exemplifies an ethos of working through power differentials across clinical, professional, and social contexts in order to form longstanding collaborations. If incorporated into the ACGME/ABPN Psychiatry Milestone Project, such recommendations will improve training gained through international experiences as well as the everyday training of mental health professionals, global health practitioners, and social scientists.

Global Health, Geographical Contingency, and Contingent Geographies

Health geography has emerged from under the "shadow of the medical" to become one of the most vibrant of all the subdisciplines. Yet, this success has also meant that health research has become increasingly siloed within this subdisciplinary domain. As this article explores, this represents a potential lost opportunity with regard to the study of global health, which has instead come to be dominated by anthropology and political science. Chief among the former's concerns are exploring the gap between the programmatic intentions of global health and the unintended or unanticipated consequences of their deployment. This article asserts that recent work on contingency within geography offers significant conceptual potential for examining this gap. It therefore uses the example of alcohol taxation in Botswana, an emergent global health target and tool, to explore how geographical contingency and the emergent, contingent geographies that result might help counter the prevailing tendency for geography to be side-stepped within critical studies of global health. At the very least, then, this intervention aims to encourage reflection by geographers on how to make explicit the all-too-often implicit links between their research and global health debates located outside the discipline.

Stress, diabetes, and infection: Syndemic suffering at an urban Kenyan hospital

The complexity of sickness among Kenya's urban poor cannot be dissociated from how social and health problems become syndemic. Increasingly diabetes and other non-communicable diseases (NCDs) are emerging among low-income populations that also are most afflicted by social stress and infection. This article examines how social stress, psychological distress, and physical illness among patients in a public hospital in Nairobi, Kenya, produce syndemic suffering, defined by lived experiences of syndemic clustering such as diabetes with depression and infection. We recruited 100 urban public hospital patients, of which half were women, and half had type 2 diabetes from June to August 2014. We administered written informed consent and collected anthropometrics and blood samples before we conducted lengthy mixed qualitative and survey interviews. We analyzed social stress in narrative interviews using content analysis and evaluated social and physical contributors to mental distress with frequency tables and logistic regression. We found that people experienced diabetes through a complex social and medical framework, where social problems were cause and consequence to psychological and physical suffering. Women's narratives revealed more social suffering as well as more mental distress and somatic symptoms, including multi-morbidities, than men's. People with diabetes reported not only concurrent anxiety and depression but also common infections, including malaria, tuberculosis, and HIV/AIDS. Narratives reveal how NCDs concurrent with infections, and HIV in particular, produce financial challenges for patients, especially when HIV treatment is free and patients must pay out-of-pocket for diabetes care. Future studies should investigate syndemic clustering of infections and NCDs among low-income populations at the population-level.

Inequitable and Ineffective: Exclusion of Mental Health from the Post-2015 Development Agenda

Alex Tsai and Mark Tomlinson argue for a place for mental health on the post-2015 development agenda.

Minimal, negligible and negligent interventions

Many interventions are not disruptive enough of the patterns that entrench poor health and health inequities. Ways forward may require a break with tradition to embrace system-focussed theory, complex logic modelling, and ways of funding and responding to problems that address the competition of ideas and needs.

Global aspirations, local realities: the role of social science research in controlling neglected tropical diseases

Neglected Tropical Diseases (NTDs) are both drivers and manifestations of poverty and social inequality. Increased advocacy efforts since the mid-2000s have led to ambitious new control and elimination targets set for 2020 by the World Health Organisation. While these global aspirations represent significant policy momentum, there are multifaceted challenges in controlling infectious diseases in resource-poor local contexts that need to be acknowledged, understood and engaged. However a number of recent publications have emphasised the “neglected” status of applied social science research on NTDs. In light of the 2020 targets, this paper explores the social science/NTD literature and unpacks some of the ways in which social inquiry can help support effective and sustainable interventions. Five priority areas are discussed, including on policy processes, health systems capacity, compliance and resistance to interventions, education and behaviour change, and community participation. The paper shows that despite the multifaceted value of having anthropological and sociological perspectives integrated into NTD programmes, contemporary efforts underutilise this potential. This is reflective of the dominance of top-down information flows and technocratic approaches in global health. To counter this tendency, social research needs to be more than an afterthought; integrating social inquiry into the planning, monitoring and evaluating process will help ensure that flexibility and adaptability to local realities are built into interventions. More emphasis on social science perspectives can also help link NTD control to broader social determinants of health, especially important given the major social and economic inequalities that continue to underpin transmission in endemic countries.