Theme leader: Steve Tollman

Verbal Autopsy with Participatory Action Research (VAPAR) – Expanding the Knowledge Base through Partnerships for Action on Health Equity 

Funders: Health Systems Research Initiative from Department for International Development (DFID)/Medical Research Council (MRC)/Wellcome Trust/Economic and Social Research Council (ESRC)

Collaborating Institutions: University of Aberdeen; Mpumalanga Province Department of Health; University of the Witwatersrand; and Queen Margaret University.                                                                                                                            PI: Dr Lucia D’Ambruoso

The VAPAR (Verbal Autopsy with Participatory Action Research) programme is a health systems research initiative to strengthen mortality data, combine this with local knowledge and interpret, plan and act in the health system. The project aims to institutionalize processes to develop the voices of communities on health priorities, and act on this information in partnership with health workers as well as multisectoral managers, planners and policy makers.

The VAPAR programme is based on twin premises: i) that there is insufficient information on health and health priorities of vulnerable, and in this case, rural, populations and ii) that there is insufficient utilisation of research evidence on the most marginalised in policy and planning. The theory is that an adaptive process of collaborative learning and action at different levels can stimulate and support decision-making, resulting in improved organisational responsiveness assisting local officials to make and implement decisions to improved services, improved community engagement and trust, and improved health behaviours and outcomes.

For more detail on the VAPAR project please visit the VAPAR website

Minimally Invasive Tissue Sampling (MITS)

Understanding who dies from what can assist researchers and policy makers in strengthening health systems and designing interventions that cater to the evolving disease burden and changing population dynamics. However, determining cause of death (CoD) in rural South Africa where clinical autopsy services are limited, upwards of at least half of deaths occur outside of health facilities and rapid and complex epidemiological transitions are underway can be difficult. While considerable efforts have been made to develop a standardized VA tool and robust methods for assigning the most likely CoD, certain conditions with nonspecific signs and symptoms make determining a CoD with the VA method difficult. As such, strengthening the current VA method by including a minimally invasive tissue sampling component will likely allow for more accurate individual-level cause of death determination and, undertaken strategically, can further strengthen the VA method. As a new member of the Minimally Invasive Tissue Sampling (MITS) Alliance and with funding received for the next 3 years, we aim to:

1.) develop and pilot methods for including minimally invasive tissue sampling (MITS) as part of routine population-based mortality surveillance in conjunction with the VA method;

2.) compare the CoD ascertained through the MITS procedure with the standard VA approach in four groups of deaths (neonates, children, maternal and adults), and

3.) broaden current scope of focus of MITS work in South Africa by ascertaining population-based CoDs in adults, piloting innovative technology and allowing for rural and urban comparative work.

In undertaking this work, we aim to contribute meaningfully to the MITS surveillance alliance and its partners.

Community-level antibiotic access and use in low- and middle-income countries; finding targets for social interventions to improve rational antimicrobial use (ABACUS) 

antibioticsThe overall aim of ABACUS is to compare community-based antibiotic access and consumption practices across a range of low and middle-income countries (LMICs) in Asia and Africa in order to inform the design of, and identify targets for community-based intervention strategies that may be used to promote rational antibiotic use. This project provides a standardized framework for appraising current antibiotic use patterns, demand and access, which may subsequently be used in other LMICs. ABACUS is currently underway in 7 of the INDEPTH HDSSs namely: Agincourt- South Africa, Metlab- Bangladesh, Manhiça- Mozambique, Filabavi- Vietnam, Kintampo and Dodowa- Ghana and Kanchanaburi.

PHIRST  – A Prospective Household observational cohort study of Influenza, Respiratory Syncytial virus and other respiratory pathogens community burden and Transmission dynamics in South Africa 

Cheryl Cohen from the Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, South Africa

Study started in December 2016 and completed follow up in December 2018
The aims of this study are to estimate the community burden of influenza and RSV, and to assess the transmission dynamics of influenza and RSV infections in the community.  This is a household-level community cohort study, has completed the three year follow up period. At each site 50 households per year were enrolled.   We collected baseline data on household composition and medical histories from all members of household, each member of the household was followed up twice weekly throughout the RSV and influenza season and annually thereafter until 2018.  Details on respiratory illness symptoms that occur, hospitalisations and deaths from respiratory illness and monthly TB symptom data were also collected.   The data should assist policy makers to understand how many people get infected with these various pathogens, understand why and how they are passed from person to person, use this data to plan interventions like vaccines to special groups of people who are at risk of becoming very ill and to make changes to programmes, like the TB programme to improve TB control.  Feedback on the study was given at a Community meeting held in November 2018. Data is being analysed and final results will be published during 2019..

Engaging Traditional Healers in Agincourt, South AfricaCollaboration with Carolyn Audet, Vanderbilt University

In both rural and urban sub-Saharan Africa, traditional healers greatly outnumber biomedical health care providers and often hold positions of authority within their communities. Individuals seek care from traditional healers for several reasons, including social acceptability, perceived source of illness, personal relationships between healers and their patients, as well as the perceived fit of a healer’s explanation of illness with patient expectations. When experiencing illness, it is common for patients to move back and forth between the biomedical and the traditional health care systems, potentially leading to delays in care, interruptions or abandonment of treatment, and herb-drug interactions. Given both the availability of traditional healers and the plural-seeking behaviour of individuals, this expanding portfolio of work seeks to develop partnerships in the delivery of health care by identifying shared beliefs between biomedical and traditional health care providers. Work to date has largely focused on HIV, with a recent grant training healers to provide HIV counseling and testing to their clients and linkage to biomedical care for those who test positive (NIAID R21AI150302). Recognizing the blood exposure risk that healers face when performing traditional ‘vaccinations’ previous work has used a ‘training of trainers’ model to train healers in the use of protective equipment – to reduce the risk of HIV acquisition (NIMH R34MH122259). Our long-term goal is to establish a sustainable and acceptable system for healer integration into the health system to improve chronic and acute health outcomes among people living in the Agincourt area.