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A Quantitative Analysis of the Health Extension Program to Inform Human Resource Policy Interventions in Ethiopia 08 May 2018

In 2004, Ethiopia launched the Health Extension Program (HEP) - a primary health care delivery strategy focussing on the delivery of 16 essential health services, targeting the rural poor. Health Extension Workers (HEWs) were employed as key vehicles for delivery of HEP. Though their deployment was in large numbers, current policy initiatives towards HEP are hampered by the dearth of empirical, quantitative data on HEW behaviours; the determinants of their job choices and the implications of these dynamics on retention policies for this workforce. This project proposes to investigate the labor market response to changes in wages, working conditions, and training opportunities of HEWs, using a discrete choice experiment. Additionally, this will be the first study to undertake an economic evaluation of available health workforce policies to provide critical insight on which policies to pursue for better retention of HEWs, as well as using mathematical modelling techniques to ascertain the causal impact of HEP on the equity of health service delivery in Ethiopia. With these three research packages, the project aims to create pioneering evidence that fills critical gaps in literature to inform human resource policy interventions in the context of HEP, leading to improvements in population health in Ethiopia.

Development of an early intervention to support babies with Congenital Zika Syndrome and their families 15 May 2017

On February 1, 2016, Zika virus (ZIKV) was designated as a Public Health Emergency of International Concern by the WHO. ZIKV has now spread to 72 countries and territories, including in Asia, Africa and the Americas. It is now clear that congenital infection with ZIKV in the first trimester can cause microcephaly, and these cases have already been reported in 20 countries. In Brazil, there are 2975 cases of microcephaly suspected of being related to ZIKV . Congenital infection with ZIKV is also linked to other congenital abnormalities, besides microcephaly, including: neurological conditions , ophthalmic abnormalities , hearing loss and bone and joint disorders . Congenital Zika Syndrome therefore extends beyond microcephaly alone. The full spectrum of conditions is not yet known, nor is there an accurate estimate of prevalence of Congenital Zika Syndrome. Congenital Rubella and CMV infection also cause neurological sequelae, including microcephaly, and for these conditions there are approximately twice as many children born with other impairments than those born with microcephaly. , Congenital Zika Syndrome is therefore likely to be at least twice as common as microcephaly alone.

Sustainable Healthy Urban Environments (SHUE) project 15 Jun 2016

The environments and governance of cities have an important role in influencing the exposures and health-related behaviours of their populations. Cities also have a demand for resources beyond current limits of sustainability. The changes needed to help reduce these local and global environmental impacts offer opportunities for improving population health by reducing current unhealthy exposures and behaviours which also contribute to patterns of unsustainable living. However, as yet there is only patchy empirical evidence on the degree to which city characteristics are associated with variations in health-related exposures, behaviours and outcomes as well as greenhouse gas (GHG) emissions. This project will build up a detailed database of a globally-distributed selected sample of cities and their populations with the aim of identifying the inter-relationship between city characteristics, their use of energy and other resources, and health-related behaviours and exposures. From comparative analyses combined with health modelling, we will assess the potential impact on health of realistic options for more sustainable strategies in such areas as transport policy and infrastructure, aiming to identify examples and principles to promote health and sustainability that can be more widely applied. The resulting database will be an open access resource for the research community and can be expanded over time.

Palm Oil: Sustainability, Health and Economics (POSHE) 15 Jun 2016

Palm oil, a ubiquitous food ingredient, has brought economic benefit to Asia, but has been linked with negative health and environmental outcomes. Previous research has found strong associations between palm oil intake and mortality from cardiovascular disease, and between oil palm production and environmental degradation. Given consumption trends in the region, potential health impacts flowing from careful policy development to restrict intake are substantial. The proposed work will break new ground in terms of (i) investigating health, economic as well as environmental aspects of palm oil, and (ii) integrating health as well as environmental aspects with a whole-economy macroeconomic model. We propose a pilot project for Thailand to (i) examine interconnections between economic, health and environmental dimensions of palm oil production and consumption. (ii) Identify and simulate the impacts of a set of policy-relevant scenarios, and (iii) test methods and data assimilation procedures, preparing the ground for a follow-on regional project. Our modelling approach involves integration of data and combination of Thailand-specific macroeconomic and health/demographic models with an environmental module. Policies will be simulated, and economic, health and environmental impacts estimated. Trade-offs and synergies will be examined, and policy recommendations made.

Changing the agenda of tuberculosis control: the impact of social protection on tuberculosis prevention, care and support. 30 Jul 2014

The post-2015 tuberculosis (TB) control strategy claims for the adoption of social protection interventions to address TB social determinants. Cash transfers are form of social protection based on the provision of cash incentives to poor households. Although increasingly popular in public health, very limited is known on the impact of cash transfer interventions on TB prevention, care and TB-related costs mitigation and ultimately TB control. Building upon a partnership with Brazil, a high TB-bu rden country with one of the largest cash transfer program in the world(i.e. Bolsa Familia), this proposal aims to contribute to address this research gap through: 1. A retrospective cohort study, comparing TB patients receiving Bolsa Familia transfers for at least 2/3 of treatment duration with patients receiving benefits for less than 1/3 of treatment (to assess the impact of financial support on treatment adherence and TB-related costs mitigation). 2. A mathematical model to explore whethe r Bolsa Familia can have an impact on TB incidence rates under different scenarios of Bolsa Familia and TB control program performance (to assess the impact of financial support on prevention).

2-year clinical follow-up of newborns with microcephaly 30 Sep 2016

To carry out a 2-year follow-up on 150 newborns with microcephaly. This study is to complement a case control study of microcephaly that started in early 2016, funded by the Brazilian government with support from PAHO and CDC. The aim of this cohort study is to consider important questions such as what are the associated disabilities, the growth and development, including cognitive development and onset of new complications and symptoms, in the first two years of life.

Building resilient health systems: lessons from international, national and local emergency responses to the Ebola epidemic in Sierra Leone. 15 Mar 2016

The response to the Ebola epidemic has challenged the dominant paradigm of gradual health systems strengthening, led by national governments and supported by international actors. It poses difficult questions about what kind of responses are helpful in situations when sudden shocks appear to overwhelm already fragile health systems and deplete limited resources. Over the last 12 months, the Ebola epidemic has revealed a lack of resilience in the health systems of affected countries, demonstrating an inability to recover from shocks and mount effective responses. We ask: In what ways has the international Ebola-response affected Sierra Leone's health system and its ability to withstand future shocks? How can international, national and local emergency response mechanisms be utilised to build a resilient health system in Sierra Leone, and what lessons emerge? Our findings will offer the potential to promote a major shift in the global health systems debate, from one narrowly focused on health system strengthening, to a focus on building health systems that are strong as well as resilient. The study will explore what needs to happen at each systems level, what capacities need to be created at local, district and national level, and what role international actors should play. To address these questions, we bring together a multidisciplinary team with extensive expertise in a range of highly relevant, but currently largely separate, bodies of scientific scholarship: health systems/health systems strengthening; policy and implementation science; disaster risk reduction/emergency preparedness; and the anthropology of global health and medical humanitarianism. Explicitly bringing together these often separate bodies of learning will enable us to more fully and effectively answer our principal research questions, identify transferable lessons and contribute to generating substantive health systems research evidence relating to what promotes resilient health systems.

Sustainable and Healthy Food Systems (SHEFS) 24 Mar 2016

The Sustainable and Healthy Food Systems (SHEFS) programme aims to understand the impact of changing food systems on the health of vulnerable populations in Africa and Asia where food system, demographic and environmental changes are set to unfold most dramatically. Building on an original analysis of multi-sectoral observational data, we will deliver innovative studies in multiple sites undergoing rapid food system change to identify the critical drivers and key interventions in food systems that can improve population health. Our study sites will provide a rich new research resource for food systems science and public health. We propose to integrate this information with inputs from socio-economic, demographic, health and earth-system models to investigate potential solutions and interventions and to establish how they might contribute to sustainable health and environment goals. We will conduct substantive new scenario modelling, considering projections that may involve complex and non-linear trends, and analysing how governance and decision-making can secure equitable and sustainable health outcomes through improved food systems in a rapidly changing world. Our goal is a step-change in the evidence base available to design food systems that improve population health whilst protecting the environment, underpinning a new generation of evidence-based policies and interventions.

Developing innovative approaches to improve treatment provision for childhood infection in peri-urban settings: A pilot study in accredited drug shops. 25 Mar 2015

Aim: To develop a health systems strategy and community-based mechanism to deliver integrated Community CaseManagement (iCCM) services to increase access to prompt effective treatment for childhood infections in peri-urban areas Objectives: i. Investigate the feasibility of two alternative community-based mechanisms (community health workers or licensed private sector drug retail outlets) to deliver iCCM in peri-urban areas ii. Develop mechanisms for governance, quality assurance, regulation, linkage with public health system (supervision, referral, health management information system) and financial sustainability, that are acceptable to treatment providers, patients, local and national authorities and regulators iii. Explore the acceptability and perceptions of a private sector delivery strategy amongst providers, users, national authorities and policy makers iv. Assess quality of iCCM services provided by trained drug retailers through a small pilot study, with focus on accuracy of diagnosis and adherence to treatment guidelines Methods: Formative research, key informant interviews, and stakeholder consultations to adapt iCCM approach and explore mechanisms to support two alternative community-based mechanisms (community health workers or drug retail outlets) to deliver iCCM services in peri-urban settings. To be followed by a small pilot study in which 10 licensed drug shops will be trained to diagnose and treat pneumonia, malaria and diarrhoea according to iCCM guidelines. The ability of drug vendors to diagnose and treat children will be evaluated through a mix of methods including: record review, clinical vignettes, participant observation, and re-assessment of a sample of patients by a qualified health worker. Participant observation and focus group discussions will explore the effects of the pilot intervention from the perspective of drug vendors, and exit interviews will examine acceptability to patients and costs incurred by households.

SPRING Programme Grant: Enhancement application for additional funds 08 Jun 2015

The goal of SPRING, Sustainable Programme Incorporating Nutrition & Games, is to develop an innovative, feasible, affordable and sustainable approach that can achieve delivery at scale of known effective interventions to maximise child development, growth and survival by using existing community-based agents (CBAs) in India and Pakistan. The SPRING intervention will be developed through extensive formative research, holding an intervention development workshop with local and international stakeh olders and experts to review the findings and make decisions about intervention content and structure, and by piloting the intervention with a few CBAs and their supervisors in order to test all operational elements. The resulting intervention will be evaluated through cluster randomised controlled trials in each setting, each involving 20 CBA supervisory zones, with 15-25 CBAs per zone, and recruiting 300 newborns per zone (a random subsample of 100 will have growth and development assessments) . Primary outcomes are infant mortality, maternal psychosocial distress at 6 months, quality of the home environment and maternal/child interaction at 1 year, and stunting and child development at 2 years. The programme will include detailed process and economic evaluations with both cost effectiveness and total cost analyses, and development of a framework for scale up to other settings.

Resisting depression stigma: exploring complementarities and contradictions 13 Jan 2016

Whilst depression itself represents a significant and growing global public health issue, so too does the stigma associated with it, given that people so diagnosed frequently experience and anticipate high levels of discrimination across the world. To date, however, there is limited knowledge about effective strategies to combat stigma related to depression. Problems with stigma concepts complicate this, too, as dissimilar processes, experiences and phenomena can constitute 'stigmatisation', with the consequence that 'stigma resistance' denotes diffuse and contradictory practices across governments, institutions, groups and individuals. This presents significant problems for people diagnosed with depression, carers, policy makers, advocacy experts and medical professionals across the world. How might they best proceed on the issue of depression stigma reduction? The main aim of this three-year sociological study is to address this problem through three interlinked research components that seek to explore complex anti-stigma discourses and practices, ultimately providing evidence which will inform future strategies and concentrate resources. To do this a heuristic of social scales is invoked, which distinguishes ‘global’, ‘national’ and ‘local’ practices. Whilst interweaved in reality, these ‘scales’ provide novel ways through which anti-stigma enactments can be explored. Together they constitute a ‘multi-sited ethnography’ of stigma resistance.

One year funding - Community-wide TB case-finding linked to a nested cluster-randomised trial of promotion of HIV-testing and prevention of HIV-rel ated TB 01 Apr 2015

The key goal is to identify a high impact strategy that could be used to achieve rapid reductions in TB incidence within a few years in high HIV prevalence urban setting. Two strategies will be investigated, first whether community-based case-finding alone can achieve this goal. An alternative possibility will be investigated through a parallel nested cluster-randomised trial: the additional impact of intensive prevention of HIV-related TB (promotion of HIV testing in the community linked t o isoniazid preventive therapy and referral for routine antiretroviral therapy). The same periodic outreach TB case-finding strategy that successfully reduced the prevalence of undiagnosed TB in Harare will be used, this time applied over a longer period (4 years) to a confluent population of 108,000 adults in order to capture the impact on TB transmission rates and new incident disease. Our community-based HIV/TB intervention will be delivered to 16,800 individual in the intervention arm of cluster randomised trial using local counsellors, including the option of supervised self-testing for HIV, and linked to community-distribution of isoniazid preventive therapy and referral for facility-based antiretroviral therapy. The key goals will be the effect on TB incidence, and acceptability and uptake of the HIV testing strategy.

The RHiSE study (Resistant Hypertension and treatment Strategies Evaluation study). 13 Apr 2015

This project will address a clear gap in RH research. The key goals of the project are: 1) to carry out a systematic review of current treatment options in RH and to analyse their comparative effects on CV outcomes. The review will also be used to identify issues around quality of existing literature and will instruct the development of the cohort study in stage three of the Fellowship. 2) to accurately estimate the incidence and prevalence of RH in the UK using Clinical Practice Research Datalink (CPRD) data. 3) to design and execute two cohort studies, one each in a UK database and a US database, which will examine the comparative effectiveness of different treatment regimens in RH in two countries. The cohort studies will allow analysis of reductions in BP and their associations with cardiovascular outcomes in RH. A methodological issue concerning missing data in the US database will be addressed as part of key goal 3. Reaching these key goals will allow delivery of t he overall objective of the project, to support the development of evidence based clinical guidelines for RH.

MEIRU - Additional funds for NCD studies 21 Apr 2015

Building on 30-years of research in Malawi, we will conduct population-based epidemiological studies with integrated laboratory and genomic analysis. Our aim is to generate policy-relevant evidence for the region. We will: 1. Determine the burden, the risk factors and the barriers to accessing care for major non-communicable diseases (NCDs) in rural and urban settings. 2. Design intervention studies to evaluate different strategies for controlling NCDs. 3. Understand patterns of transmi ssion and the factors associated with virulence of M.tuberculosis in Karonga in a setting of unusually well implemented routine tuberculosis control in order to contribute knowledge towards the goal of tuberculosis elimination. 4. Determine the long-term impacts of antiretroviral therapy on mortality, reproductive health and family welfare in the rural population and investigate changes in treatment strategies that will maximise population level benefits. 5. Evaluate the impact of Malawi's newly introduced HIV test-and-treat strategy for pregnant women on retention in care and on mother-to-child HIV transmission in real-life urban and rural African settings. 6. Develop Malawian research capacity in epidemiology, medical statistics and demography. 7. Strengthen links with the Malawi Ministry of Health and the College of Medicine and form collaborations with public health institutions in the region

Future diets and health: how will environmental changes affect food availability, food consumption and health 07 May 2015

This project aims to answer the primary research question: Will the projected impacts of environmental changes on terrestrial food production and food quality have a demonstrable influence on nutrition and health outcomes over the next 20-30 years? The project will establish an interdisciplinary approach encompassing environmental, agricultural, nutrition, health, mathematical and social sciences to enable the mapping and quantification of the multiple pathways between environmental change and population-level food availability, food quality, dietary intake, nutrition and health outcomes over the coming decades. By taking a broad, interdisciplinary analytical approach, and applying it to country case studies, this project aims to test whether current projections of changes in agricultural production, food availability and food quality are likely to result in quantifiable impacts on nutrition and health outcomes. Key goals: 1. Define an evidence-based analytical framework linking environmental change with nutrition and health outcomes. 2. Apply the framework to three countries (UK, Mexico and Ethiopia) to identify critical nodes where policy-level action may influence nutrition and health. 3. Establish a method and analytical baseline for future modelling and scenario testing and make an inter-sectoral dataset on agriculture, food prices, nutrition and health available for public use.

Rapid Urine-Based Screening for Tuberculosis to Reduce AIDS-Related Mortality in Hospitalized Patients in Africa (STAMP) Trial 03 Jun 2014

Does implementation of anovel, rapid, high sensitivity urine-based screening strategy for TB used in combination with routinesputum-based standard of care diagnosis reduce all-cause mortality among HIV-infected medicalin-patients newly admitted to hospitals in southern African countries?

Health and environmental implications of low-carbon, climate-change resilient diets in India 27 Mar 2014

There is currently no information available on the greenhouse gas (GHG) emissions associated with dietary patterns in India, or the possible options for producing low emission, climate-change resilient diets, and their health consequences. This study aims to identify healthy, low-carbon, climate-change resilient diets that are culturally-appropriate and policy-relevant in India. We will characterise dietary patterns in India and estimate their GHG-related emissions. Using mathematical methods these diets will be modified to minimise deviation from current patterns while meeting dietary guidelines for health and minimising GHG emissions and water footprints, incorporating climate-resilient crops where possible. We will provide a suite of policy and climatechange relevant dietary recommendations for the Indian setting. Key goals: 1) Identify current adult dietary patterns and their associated GHG emissions and nutritional content; 2) Characterise the consumers of each pattern with respect to socio-demographics and geography; 3) Identify achievable, culturally acceptable dietary changes for different population groups that will be healthy, low-carbon and climate-change resilient; 4) Quantify the health impacts associated with these dietary changes; 5) Provide a suite of context-relevant options for agricultural, nutritional and health policy makers

Training Health Researchers into Vocational Excellence in East Africa (THRiVE). 16 Sep 2013

1. Develop and sustain a consortium functioning as a strong network by: i. Exchange of staff ii. Developing collaborative research projects iii. Regular communication between consortium members iv. Adjunct appointments of senior research scientists v. Joint academic programmes attended by trainees from THRiVE vi. Joint annual meetings vii. Joint supervision of PhD students 2. Empower institutions to build a critical mass of well trained research scientists capable of winning competitive national and international grants i. Mount modular short courses. These will contribute towards PhD and Masters training. ii. Enhance quality of masters training at KCMC (with emphasis on epidemiology, biostatistics and clinical trials), Gulu University and National University of Rwanda iii. Establish, and model, high-quality systems for selection, supervision and mentorship of fellowships/internships: ? Undergraduate internships ? Masters fellowships ? PhD training ? Post-doctoral fellowships 3. Augment the development of a conducive institutional environment i. Improve electronic communication, maintain website and facilitate high-speed internet access ii. Ensure availability of basic and advanced laboratory facilities iii. Identify/support key senior positions for supporting research training and mentoring 4. Support systems for improved governance/management of research activities i. Strengthen research administration and resource mobilization at participating institutions ii. Establish staff development programmes