r4d Mixed Methods Research Workshop

The Swiss Programme for Research on Global Issues for Development organized an r4d Skills Mixed Methods Research Workshop with Alicia O’Cathain, on integration and quality assessment. The full-day workshop took place in Bern on 28 October 2016 and congregated project leaders, project coordinators and Ph.D. students of r4d projects funded by the Programme, including COHESION.

Alicia O’Cathain is a Professor of Health Service Research, University of Sheffield, UK; and has published widely on mixed methods, mixed teams and randomized control trials. During the workshop, Dr. O’Cathain engaged participants in sessions covering definitions, rationales, designs, reporting, integration of qualitative and quantitative data, and assessing quality.

Four members of the COHESION team (Jorge Correia, Nathaly Aya Pastrana, Olivia Heller, Sarah Lachat) and one member of the project Advisory Board (Dr. Sigiriya Aebischer-Perone) participated in the workshop. Team members discussed and reflected on how to integrate and disseminate the findings of   data to be collected by the Project, balancing the insights obtained from qualitative methods with those from quantitative methods. Dr. Aebischer-Perone will share the reflections during the first Swiss COHESION Advisory Board meeting in Geneva on 21 November 2016.

To find more information about the workshop click here

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Swiss based Advisory Board meets in Geneva

The members of the Swiss-based Advisory Board meet in Geneva today (21 November 2016) to discuss the project. Many thanks to the following for agreeing to this important position:

  • Dr. Sigiriya Aebischer-Perone, HUG
  • Carlos Briceno, Permanent Mission of Peru
  • Lauranne Botti, CORHED
  • Anthony Costello, WHO
  • Dr. Gilles Eperon, HUG
  • Peter Godfrey-Faussett, UNAIDS
  • Dr. Yves Jackson, HUG
  • Maria Jesus Alonso Lormand, International Solidarity Office of Canton of Geneva
  • Pablo Perel, LSHTM/WHF
  • Francelina Romao, Mozambique Permanent Mission
  • Surendra Yadav, Permanent Mission of Nepal

COHESION meets to analyze NTD & NCD policies

On 14 November 2016, five members of the larger Global Policy Analysis team met in Geneva. Led by Dr. Claire Somerville (The Graduate Institute), and following Shiffman’s Political Priority framework, the team identified preliminary themes across NTD and NCD documents and resolutions in the actors and actor power, ideas, political contexts, and issue characteristics. Very interesting findings so far.

More to come from both the global and national policy analysis teams soon.

 

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Selecting the NTD in Peru

“Selecting the NTD in Peru:
Engaging stakeholders in the difficult decision of selecting what underserved disease to prioritize”

The COHESION Project aims to address the double burden of disease that face health systems and communities by improving capacities at the national, local and community levels in three countries (Mozambique, Nepal and Peru). To assess the barriers that underserved communities face when accessing Primary Health Care (PHC) each country team selected a Neglected Tropical Disease (NTD) and two Non-communicable Diseases (NCDs) (diabetes and hypertension). These three diseases would be used as “tracer” conditions to understand the challenges of local health systems to effectively manage these diseases at the PHC level.

Why tracers? Because individuals with one or both, NTD or NCD, have the unique scenario of requiring chronic, engaging, meaningful, respectful and effective care. Both of these tracers, NTDs and NCDs, allow us a second chance to get it right, to redefine the user experience with our healthcare system.

In Mozambique, the selected NTD was Schistosomiasis, while the Nepalese team chose Leprosy. In Peru, we had initially selected Chagas but we felt we needed more information about the various NTDs with chronic sequels affecting people in Peru before making a final decision.

After several discussions with experts and internal conversations about the appropriateness of Chagas and other NTDs including Leprosy, Hydatidosis and Neurocysticercosis, we decided on Neurocysticercosis.

In this post, we share the reasons that lead us to this decision.

We first contacted an expert in Leprosy. We learned that it has not been fully eradicated in some regions in Peru, although the national prevalence rate is lower than 1 case x 10 000 inhabitants (Burstein, 2014). Leprosy still affects some small localities of the Amazon regions, where several geographical barriers and a dispersion settlement pattern predominate (Burstein, 2014). Addressing Leprosy is a challenge given the under diagnosis and other problems related with the epidemiological information systems for reporting of new cases.

Chagas disease affects over 8 million people in the Americas and about 190,000 persons with this disease live in Peru (Bayer et al., 2009). After different national and regional efforts in the nineties for the elimination of the Chagas vector (Triatoma infestans), the incidence of this disease was reduced. The main region affected in Peru is Arequipa, in the Southern Andes. As a result of efforts from different public and private institutions the vectorborne transmission of the disease has been significantly reduced and is now located in peri-urban shantytowns near the city of Arequipa as a response of urbanization processes and migration (Delgado et al., 2011). There is still work to do to eradicate Chagas, starting with the approval of a standardized protocol for the management of the disease and intensification of efforts in diagnosing people plus more thorough surveillance activities with special focus in shantytowns (Bayer et al., 2009). One reason that leads us to reconsider Chagas as the selected NTD is that symptoms may take about 20 years to develop and only few persons who have lesions show a recovery after pharmacological treatment. Additionally, the migration of the disease to peri-urban zone would leave us without the opportunity to explore the response of PHC for patients with NTD in rural area and to develop strategies to enhance the user experience with services provided by the PHC.

When exploring Hydatidosis and Cysticercosis, we learned that “controlling the parasitic infection in animals is crucial to reduce the incidence of human disease” (Otero-Abad & Torgerson, 2013). Both diseases are closely related with human behavior, for example with education about the transmission of the diseases and the prevention with hygiene actions. Currently, there is no vector control program for Hydatidosis in Peru. There was an effort for developing a program that included radio programs with educational messages and the empowerment of school teachers as providers of health and sanitary messages. However, control programs and educative activities were discontinued. Moreover, this disease is not notifiable in Peru, which makes it harder to know its current prevalence.

Finally, we looked into Neurocysticercosis (NCC), which is an “infection of the nervous system by the cystic larvae of Taenia solium” (Garcia, Nash, & Del Brutto, 2014) that frequently causes seizures and epilepsy. Worldwide, over 5 million cases of epilepsy are caused by Neurocysticercosis (Nash, Mahanty, & Garcia, 2013). Neurocysticercosis is especially endemic in areas characterized by poor water and sanitation systems and where pigs are not corralling with access to human feces (García, Gonzalez, Evans, & Gilman, 2003). In Peru, Neurocysticercosis affected approximately 35% of persons with active epilepsy, which is a very high rate comparable with Honduras and India. Only one out of every four patients with active epilepsy receive pharmacological treatment, but in sub-therapeutic doses (Moyano et al., 2014). It has been demonstrated that the transmission of Taenia solium was eliminated in 105 of 107 villages in Tumbes (region located in the north of the country) after an “attack phase” during one year that comprises people and pigs, and this result persisted over 1 year (Garcia et al., 2016; Maurice, 2014). However, there are still cases of NCC in the intervened region after several years of the implementation of the control program and there are other endemic regions affected by this disease in Peru.

The aforementioned efforts for the different NTDs and the pending actions for reaching the control of the diseases were the main topics discussed with different experts in the field. We were impressed with their high motivation, solidarity and expertise gained through the years. For example, there are strong research teams for the study of Chagas and Cysticercosis that have made relevant contributions like the risk mapping of the zones to inform surveillance system for Chagas or the massive intervention in persons and pigs from rural villages of northern Peru for blocking transmission of cysticercosis.

All experts agreed that whatever NTD we chose, we would be making a difference because they affect the most vulnerable.

Our decision about the selection of Neurocysticercosis for the purpose of the COHESION project was made considering to prioritize an NTD that generates a chronic condition that requires long-term treatment like epilepsy and affecting the poor of the poorest population in rural area, where PHC response is more relevant as the first point of entry for care. In so doing, by choosing NCC, together with an understanding of other major prevalent NCD conditions like diabetes and hypertension, will provide us with a second chance to get it right, to redefine the user experience within our healthcare system.

Acknowledgments: We thank César Náquira, Ricardo Castillo, Valerie Paz-Soldán, Aldo Lucchetti, Luz María Moyano, Ricardo Gamboa and H. Hugo García for their valuable time and insights about NTDs for the purpose of the COHESION project.

References:

Bayer, A. M., Hunter, G. C., Gilman, R. H., Carpio, J. G. C. del, Naquira, C., Bern, C., & Levy, M. Z. (2009). Chagas Disease, Migration and Community Settlement Patterns in Arequipa, Peru. PLOS Negl Trop Dis, 3(12), e567. http://doi.org/10.1371/journal.pntd.0000567

Burstein, Z. (2014). Critical appraisal about control programs and elimination of leprosy in Peru, and its consequences for Peru and America. Revista Peruana de Medicina Experimental Y Salud Pública, 31(2), 336–342.

Delgado, S., Neyra, R. C., Machaca, V. R. Q., Juárez, J. A., Chu, L. C., Verastegui, M. R., … Levy, M. Z. (2011). A History of Chagas Disease Transmission, Control, and Re-Emergence in Peri-Rural La Joya, Peru. PLOS Negl Trop Dis, 5(2), e970. http://doi.org/10.1371/journal.pntd.0000970

García, H. H., Gonzalez, A. E., Evans, C. A. W., & Gilman, R. H. (2003). Taenia solium cysticercosis. Lancet, 362(9383), 547–556. http://doi.org/10.1016/S0140-6736(03)14117-7

Garcia, H. H., Gonzalez, A. E., Tsang, V. C. W., O’Neal, S. E., Llanos-Zavalaga, F., Gonzalvez, G., … Gilman, R. H. (2016). Elimination of Taenia solium Transmission in Northern Peru. New England Journal of Medicine, 374(24), 2335–2344. http://doi.org/10.1056/NEJMoa1515520

Garcia, H. H., Nash, T. E., & Del Brutto, O. H. (2014). Clinical symptoms, diagnosis, and treatment of neurocysticercosis. The Lancet Neurology, 13(12), 1202–1215. http://doi.org/10.1016/S1474-4422(14)70094-8

Maurice, J. (2014). Of pigs and people—WHO prepares to battle cysticercosis. The Lancet, 384(9943), 571–572. http://doi.org/10.1016/S0140-6736(14)61353-2

Moyano, L. M., Saito, M., Montano, S. M., Gonzalvez, G., Olaya, S., Ayvar, V., … Peru, for T. C. W. G. in. (2014). Neurocysticercosis as a Cause of Epilepsy and Seizures in Two Community-Based Studies in a Cysticercosis-Endemic Region in Peru. PLOS Negl Trop Dis, 8(2), e2692. http://doi.org/10.1371/journal.pntd.0002692

Nash, T. E., Mahanty, S., & Garcia, H. H. (2013). Neurocysticercosis—More Than a Neglected Disease. PLOS Negl Trop Dis, 7(4), e1964. http://doi.org/10.1371/journal.pntd.0001964

Otero-Abad, B., & Torgerson, P. R. (2013). A Systematic Review of the Epidemiology of Echinococcosis in Domestic and Wild Animals. PLOS Negl Trop Dis, 7(6), e2249. http://doi.org/10.1371/journal.pntd.0002249

 

COHESION in the The Lancet Diabetes & Endocrinology

The Lancet Diabetes & Endocrinology has just published a commentary from the COHESION investigators on “The need to focus on primary health care for chronic diseases“.

DOI: http://dx.doi.org/10.1016/S2213-8587(16)30148-6

Beran, D., Chappuis, F., Cattacin, S., Damasceno, A., Jha, N., Somerville, C., Suggs, L.S., Miranda, J. J., for the COHESION Project (2016, July 15). The need to focus on primary health care for chronic diseases. The Lancet Diabetes & Endocrinology. http://doi.org/10.1016/S2213-8587(16)30148-6

Views from the World Cardiology Congress

COHESION at the heart of the matter: Views from the World Cardiology Congress
by COHESION Principal Investigator, Dr. David Beran

I was invited to give a talk at the World Cardiology Congress on lessons from diabetes and health systems that might be of use for cardiology. An interesting opportunity and when I found out that my co-Investigators Albertino Damasceno and Jaime Miranda would also be there I saw it as an added advantage to be able to see them and catch up on COHESION.

On my flight to Mexico, the Congress was in Mexico City, the person sitting next to me on the flight asked if I was going to Mexico on holiday and I said no that I was going to a Congress. They asked which Congress and I said a cardiology congress. “Ah so you are a cardiologist?”, my neighbour asked. “No” was my answer. “Then what kind of doctor are you?”, was his retort. “Actually, I am not a doctor, I work in public health and health systems”, I replied and started describing what I actually do. Luckily the bewilderment of my fellow rowmate was interrupted by the all too important question by the flight attendant͞, “Chicken or pasta?” At which point we wished each other a pleasant meal and that was the end of our interaction.

That brief contact with my fellow traveller highlighted many things. One, the view of health as that of a doctor’s domain. Secondly, that public health is a misunderstood concept and people outside the health arena do not really understand what it means. Another issue is that for many people when they hear a disease, e.g. cardiology, they see this as something that doctors and medicine can fix, versus a large societal health issue that requires multiple actors to address within and outside the health system. Finally, that I need to find a better way of explaining what I do…

These issues are essential to highlight based on this somewhat trivial interaction in that at the World Cardiology Congress many of the sessions were geared towards issues that could not have been further away from what my travel companion imagined what cardiology and a cardiology congress entailed. I attended interesting discussions on tobacco, alcohol, health systems and specificities of heart disease in different parts of the world, e.g. Africa versus Latin America. All of the presentations had one thing in common, that the COHESION project is well and truly at the heart of the matter.

To give you an example why I say that. The sessions discussing tobacco, alcohol or obesity or those discussing hypertension management highlighted that these phenomena once thought of as being only found in high-income countries have now become global issues impacting all strata of populations within and between countries. In parallel certain countries face this burden as well as the burden of cardiovascular disease linked to infectious agents such as Rheumatic Heart Disease. For an excellent review of the challenges of cardiovascular disease in poor populations see http://www.ncbi.nlm.nih.gov/pubmed/27297348 which Jaime Miranda contributed to. These examples highlight the double burden of disease as a challenge, but very few of the presentations or discussion highlighted what could be done. Many described possible avenue for improvement: strengthening health systems, better health promotion and prevention activities, the need for policy interventions, better training of health professionals, task shifting, use of “m” and “e” health, etc. None of the presentations I attended mentioned two of the cornerstones of the COHESION project namely Primary Health Care or the community.

This made me realise the importance of the COHESION project in not only addressing the specific NCDs and NTDs we are working on, but also wider health system issues. Also seeing my two co-Investigators discuss the work they do in parallel to COHESION highlighted the quality of the individuals we have and how they truly are at the forefront of their fields. Hopefully, in the future, the COHESION team will be able to present its results in such a forum highlighting lessons learnt from NCDs and NTDs in improving PHC for other conditions.

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Jaime Miranda, David Beran, Albertino Damasceno

 

COHESION @World Health Assembly 2016

The COHESION project was at the World Health Assembly,

“the decision-making body of WHO. It is attended by delegations from all WHO Member States and focuses on a specific health agenda prepared by the Executive Board. The main functions of the World Health Assembly are to determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The Health Assembly is held annually in Geneva“ (http://www.who.int/mediacentre/events/governance/wha/en/).

Six members of the COHESION team (David Beran, Claire Somerville, L. Suzanne Suggs, François Chappuis, Jorge Correia, and Sarah Lachat) attended various sessions on NCDs, NTDs, patient safety and more. In this blog post, Sarah and Jorge highlight some of their key take home messages relevant to COHESION.

  1. The opportunity to integrate NCDs and NTDs care into PHC as well as to address their risk factors is clear. The growing political engagement and promising initiatives at global and regional levels to ensure that “no one is left behind” (UHC approach) and to improve global health security after the Ebola crisis make addressing the double burden of NTDs and NCDs not only appropriate but also essential. For example:
  2. At the same time, there is a need for making an investment case for NCDs and NTDs integration due to difficulties to obtain quality data in terms of socio-economic related costs at country level (e.g. loss of productivity, DALYs, etc.).
  3. In alignment with the SDGs, there is a global shift from vertical approaches to integrated care and shared agreement on the necessary multi-sectorial integrated approach to tackle prevention of NCDs. However, there is difficulty in introducing systemic primary prevention measures due to conflicting interests.
  4. There is an underestimated bidirectional link between health and climate change: e.g. growth of vector born diseases due to global warming; increased chronic respiratory diseases linked to air pollution.
  5. Health policy is essential to tackle disease but community and individual initiatives bottom-up approach are equally important.

Click here to read more about the World Health Assembly 2016

 

Photo of Mrs. Lachat and Dr. Correia at the WHA 2016

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FeaturedWHO is the COHESION Project?

COHESION is the acronym of COmmunity HEalth System InnovatiON Project. It brings together institutions from Mozambique (Universidade Eduardo Mondlane), Nepal (B.P. Koirala Institute of Health Sciences), Peru (Cronicas Centre of Excellence in Chronic Disease at the Universidad Peruana Cayetano Heredia) and Switzerland (University of Geneva, Geneva University Hospitals, Graduate Institute and the Università della Svizzera italiana) with a focus on improving the management of Noncommunicable (NCD) and Neglected Tropical diseases (NTD) at Primary Health Care (PHC) for vulnerable populations.

Rather than focus on the “what” of the project: NCDs, NTDs and PHC; or the “how”: mixed methods, co-creation, innovative, adapted interventions at the community level and active communication with a variety of stakeholders, the first blog post of the COHESION Project will be on the “who”.

So who is the COHESION Project? The core team is comprised of leading academics in the fields of public health, epidemiology, clinical medicine, economics, sociology, gender, social marketing, communication, and anthropology. With many years of experience in different settings and across disease areas, the COHESION Team brings together a unique group of people. The sum of these individuals is an exceptional team with a unique set of skills and experience.

How did this team come together? This team is brought together by long-standing working relationships, joint projects, membership of similar networks, but most importantly a shared vision of:

  1. Mutual learning
  2. A focus on the most vulnerable
  3. Health systems strengthening
  4. Robust design and evaluation of complex interventions

The proposal and its approach were developed by the whole team building on the needs of the most vulnerable populations in the three countries as well as on the skills and expertise of the country groups and their members. Together we agreed on the proposal and its approach and in doing so became a cohesive team and highly motivated to make the COHESION Project a success.

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