In partnership with the Biomedical Research Training Institute in Zimbabwe, we are conducting social science research focused on adolescent health in Zimbabwe.

Constance Mackworth-Young is the lead social scientist for this work, supported by Sarah Bernays, as the senior social science advisor (both members of the Department of Global Health and Development). The social science research is embedded within projects and trials on Adolescent Health led by Rashida Ferrand, Director of the Zimbabwe-LSHTM Research Group.

Studies

Process evaluation of the CHIEDZA trial: a community-based sexual and reproductive health intervention for adolescents

CHIEDZA, which stands for Community based interventions to improve HIV outcomes in adolescents: a cluster randomised trial in Zimbabwe, is a two-year study to develop and evaluate the impact of a community-based, youth-friendly reproductive and sexual health service on improving HIV outcomes in people aged 16-24. STI screening within CHIEDZA (STICH) is a sub-study which aims to evaluate the effectiveness of community-based screening for STIs among youth in Zimbabwe.

We are conducting a process evaluation of both CHIEDZA and STICH, which aims to understand the intervention's implementation, mechanisms of action, and the role of local context to inform and understand the intervention. The MRC Process Evaluation Framework informs this study. Specific service focuses include on HIV, STI screening and family planning. Methods include non-participant observation of intervention sites, interviews with clients and providers, and participant observation of team meetings.

People

• Rashida Ferrand
• Constance Mackworth-Young
• Sarah Bernays
• Constancia Mavodza
• Suzanna Francis
• Joanna Busza
• Maureen Tshuma
• Rangarirayi Nyamwanza
• Portia Nzombe

Y-CHECK: Co-designing routine health check-ups during adolescence

The Y-CHECK study seeks to co-design and evaluate an intervention programme to screen, treat and refer adolescents for a range of common health conditions using routine health check-ups undertaken at two time points during adolescence (the first between 10 to 14 years, and the second between 15 to 19 years).

Zimbabwe is one of the three sites where the study is being conducted, alongside Ghana, and Tanzania. It is coordinated by the World Health Organization, in collaboration with London School of Hygiene and Tropical Medicine, Biomedical Research & Training Institute in Zimbabwe, University of Ghana School of Public Health and Mwanza Intervention Trials Unit.

Through a process of co-design with adolescents, parents, healthcare professionals, teachers and key stakeholders a routine health check-up design was created. This entailed a review of existing programmes and data, key informant interviews and workshops using participatory approaches with all stakeholders. The co-designed intervention will be piloted and its effectiveness and cost-effectiveness will be evaluated, pending funding.

People

• David Ross
• Rashida Ferrand
• Grace McHugh
• Constance Mackworth-Young
• Rudo Chingono
• Helen Weiss
• Aoife Doyle

The Anthropology of Antimicrobial Resistance (AMR) Research Group applies ethnographic approaches and social theories such as pharmaceuticalisation, care, global health assemblages and multi-species perspectives to the study of AMR. We currently have seven ongoing projects with collaborators in a number of low and middle-income countries, including Uganda, Zimbabwe, Malawi, Thailand and Myanmar. Our work addresses numerous topics, including pharmaceutical supply chains, prescribing practice in clinics and hospitals, clinical guidelines and algorithms, antibiotic use in residential and farm settings, and the roles of the private and informal providers.

Our approach is grounded in a commitment to slow thinking and exploring alternative ways of thinking about the 'problem' of AMR to those offered in prevailing discourses. In particular we seek to move beyond approaches which centre the individual and their behaviour and to instead foreground the complex interactions between epidemiology, economics, infrastructure, politics and culture that lead people use and depend on antimicrobials. To this, we use both discourse analysis to examine the framing of AMR in the global policy arena, as well as in-depth ethnographic research to examine antimicrobial use in context and the effects of AMR interventions in local worlds.

Studies

Antimicrobials in Society (AMIS) Hub – involves research in Uganda and Thailand, and a platform to stimulate fresh perspectives in social research on AMR.

Febrile Illness Evaluation in a Broad Range of Endemicities (FIEBRE) – a fever aetiology study with social science work on antimicrobial use in Zimbabwe, Malawi and Myanmar.

Drivers of Resistance in Uganda and Malawi (DRUM) – research in Malawi and Uganda into how antimicrobial use in humans, animals and wider environment contribute to AMR.

Capacity Sharing for AntiMicrobial Stewardship (CaSAMS) – a collaboration between UK and Ugandan institutions to establish an antimicrobial stewardship committee at a referral hospital in Uganda.

Impact of a Typhoid Conjugate Vaccine Campaign on Antimicrobial Use in Harare, Zimbabwe (TAZ) – a multidisciplinary project investigating how a mass typhoid vaccination in Harare in 2019 has affected antimicrobial prescribing practices

People

• Clare Chandler
• Laurie Denyer-Willis
• Anna Perris
• Coll Hutchison
• Justin Dixon
• Eleanor MacPherson  
• Nicolas Fortane
• Chris Pinto
• Jenny Westad

Resources and Publications

Addressing antibiotic use: insights from social science around the world
Alice Tompson and Clare Chandler
2021
Technical Report. London School of Hygiene & Tropical Medicine. 

Antibiotics, rational drug use and the architecture of global health in Zimbabwe
Justin Dixon, Salome Manyau, Faith Kandiye, Katharina Kranzer and Clare Chandler
2021
Social Science & Medicine

Quick fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse
Laurie Denyer-Willis and Clare Chandler
2019
BMJ Global Health

Knowing antmicrobial resistance in practice: a multi-country qualitative study with human and animal healthcare professionals
Maddy Pearson & Clare Chandler
2019
Global Health Action

The ‘Drug Bag’ method: lessons from anthropological studies of antibiotic use in Africa and South-East Asia
Justin Dixon, Eleanor MacPherson, Salome Manyau, Susan Nayiga, Yuzana Khine Zaw, Miriam Kayendeke, Christine Nabirye, Laurie Denyer Willis, Coll de Lima Hutchison and Clare I. R. Chandler
2019
Global Health Action

Antibiotic prescribing and resistance: Views from low- and middle-income prescribing and dispensing professionals
Doble A, Glogowski R, Ibezim S, Lazenby T, Heilie Redai A, Shaikh N, Treharne A, Yardakul S, Yemanaberhan R, Reynolds L, Chandler C
2018

Anthropology’s contribution to AMR control
Laurie Denyer-Willis and Clare Chandler
2018

The modern era must end: antibiotic resistance helps us rethink medicine and farming
Coll de Lima Hutchison, Gwen Knight, Richard Stabler, Clare Chandler
2018
BMJ

Addressing Antimicrobial Resistance Through Social Theory: An Anthropologically Oriented Report
Clare Chandler, Eleanor Hutchinson, Coll Hutchison, C 2016
Technical Report. London School of Hygiene & Tropical Medicine

The Constructing of Antimicrobial Resistance: A Workshop. 3rd August 2016, Latimer Place, Chesham, UK

Antimicrobial Resistance and Anthropology: Research Brief
Chandler, C.I.R., and Hutchinson, C.
2016
ESRC AMR Research Champion/University of Bristol

Over the past decade there has been a considerable amount of work at the MRC/UVRI and LSHTM Uganda Research Unit, and over the past 5 years at the Africa Health Research Institute, focused on the health and wellbeing of children and young people.  This has been led by Janet Seeley and colleagues in Uganda and South Africa, and Zimbabwe.  Janet often works in collaboration with Sarah Bernays, as well as experienced social scientists in Uganda (Godfrey Siu, Agnes Ssali, Rachel Kawuma, Flavia Zalwango and Andrew Ssemata) and South Africa (Nothando Ngwenya, Thembelihle Zuma, Rujeko Samanthia Chimukuche, Busisiwe Nkosi and Oluwafemi Adeagbo).  Two current examples:

Studies

Lending a hand: developing a support structure for young migrants in South Africa and Uganda

A significant proportion of young people in sub-Saharan Africa migrate to towns or cities, where they hope to find work and build their livelihood. Our aim is to develop and test the acceptability and feasibility of a protective support structure for young migrants (aged 14-24 years old) in urban settings in South Africa and Uganda as means of early intervention to reduce the harm of patterns of risk behaviour (sexual risk and violence) associated with youth migration.

Specifically we are 1) establishing a small peer supporter network in three sites in Uganda and South Africa to provide advice and support over the telephone to young migrants; 2) offering a call hub staffed by a peer-supporter during the day and early evening who can provide information and onward referral to local health and social services, information on safe spaces where items such as free condoms are available and access to a counsellor/nurse for advice (this list may be modified/adapted following the planning phase with young people in the first few months of the study)  and 3) supporting local (adult) champions and local resources/safe spaces to enable a supportive environment for the well-being adolescent and young people who are migrants.  This project is funded through the MRC/DFID/NIHR Adolescent Health Call.

ODYSSEY (Once daily dolutegravir based ART in young people vs. standard therapy). A randomised trial of dolutegravir (DTG)-based antiretroviral therapy vs. standard of care (SOC) in children with HIV infection starting first-line or switching to second-line ART (PENTA 20)

The social science component of this trial – which Sarah Bernays and Janet Seeley lead – is to investigate how best to support children and young people to maintain optimal adherence to second-line HIV treatment. Participants enrolled in ODYSSEY B aged 10-18 years who have known about their HIV status for a minimum of six months have been recruited. We are working in two ODYSSEY trial sites in Uganda Zimbabwe, Harare in Zimbabwe.  We have recruited 20 participants (40 in total) in each site and conducted two in-depth individual interviews and a series of focus group discussions with the trial participants at different stages of the trial will be conducted.

Multimorbidity – the coexistence of multiple chronic conditions in one individual – has become an increasingly pertinent health challenge as people live longer. Long known to be more the rule than the exception in the global north, multimorbidity is also increasingly being recognised as a key health challenge facing nations in the global south. Yet, the architectures of science, healthcare and indeed the very way we classify and conceptualise disease remain organised along single-disease and single-organ lines. The KnowM study, supported by a Wellcome Trust Fellowship in Humanities and Social Science held by Justin Dixon, brings together a wide range of researchers, policymakers, healthcare professionals and patient groups to develop an interdisciplinary conceptual framework and research strengthening agenda for responding to multimorbidity in the global south. The project is conducted through the Zimbabwe-LSHTM Research Partnership, in collaboration with the Organisation for Public Health interventions and Development (OPHID).

Research Approach

The KnowM study combines ‘traditional’ ethnographic fieldwork in research and care settings in Zimbabwe with a series of collaborative research activities. This includes ‘collaboratory’ experiments (bringing pairs together from different communities of practice to observe and reflect upon one another’s practices), participatory workshops to interrogate concepts for understanding multimorbidity, and virtual multi-country symposia – all of which will progressively work towards co-producing research outputs. These methods are designed to cut through disciplinary and disease siloes and move beyond entrenched binaries such as ‘communicable’ and ‘noncommunicable’, ‘acute’ and ‘chronic’ and biological and social that persistently work against more effective and equitable health work.

People involved:

• Justin Dixon
• Clare Chandler
• Rashida Ferrand
• Chiratidzo Ndhlovu
• Emily Mendenhall
• Karen Webb

Studies

The direct and indirect effects of HIV/ AIDS on the Health and wellbeing of older people study (WOPS). Wave 5 (externally funded by NIA/NIH through WHO).

A collaboration with WHO. The overall goal is to contribute evidence to guide the development and implementation of health programmes to meet older people's needs, especially those living with or otherwise affected by HIV. A detailed survey will be conducted with approximately 600 people aged 50 and over in Kalungu, Masaka and Entebbe, using the tool and approach used in Waves 1, 2, 3 and 4.  Waves 1-3 were also conducted in South Africa, providing valuable comparative data for the two countries.

The impact of COVID-19 on older people in KwaZulu-Natal, South Africa

The process of ageing and the superimposed pressures caused by life events related to the HIV epidemic, co-morbidities, the COVID-19 pandemic and the associated lockdown have multiple interrelated implications for older people (60 years and older).  The combination of the stress about daily living and fears of infection with SARS-CoV-2 have the potential to affect the health of older people. There are several studies on the experiences of  grandparent caregivers in the context of the HIV-epidemic, and some work on older people living with HIV, but limited work to date on the experience of older people living through, or once lifted, lived through lock down and who may experience anxiety caused by the knowledge that they are particularly at risk from COVID-19 infection.  This project aims to fill this gap by situating a longitudinal study using qualitative methods to study the impact of COVID-19 and the lock down on older people in the PIP area in uMkhanyakude. We are collecting oral diaries, once a month for six months (October 2020 to March 2021).  Janet Seeley in working with Nothando Ngwenya, Ntombizonke Gumede and Anita Edwards.

The research examines ‘preparedness from below’ – the understandings and practices of communities through which they anticipate and manage disease threats such as COVID-19 on a daily basis. We aim to identify entry points and pathways for connecting global, intermediate and local ‘assemblages’ in ways that build on, enhance and support the legitimacy and agency of communities’ ‘preparedness from below’. Ethnographic fieldwork is being conducted in Sierra Leone and Uganda.

People:

• Melissa Parker
• Fred Martineau

Partner organisations include:

• Institute of Development Studies, Sussex
• Centre Régional de Recherche et de Formation à la prise en charge de Fann (CRCF, Senegal)
• Institut de recherche pour le développement
• Njala University
• Gulu University

Publications

Parker, M., MacGregor, H and Akello, G 2020. COVID-19, public authority and enforcement. Medical Anthropology. https://doi.org/10.1080/01459740.2020.1822833

Baluku, M., Akello, G., Parker, M and Grant, C 2020. How the ‘disease of the radio’ is affecting people on the Uganda-DRC border. https://www.ids.ac.uk/opinions/covid-19-how-the-disease-of-the-radio-is-affecting-people-on-the-uganda-drc-border/

MacGregor, H., Leach, M., Wilkinson, A and Parker, M. 2020. Covid-19 – a social phenomenon requiring diverse expertise. https://www.ids.ac.uk/opinions/covid-19-a-social-phenomenon-requiring-diverse-expertise/

The Politics and Anthropology of Violence and Epidemics (PAVE) team are an anthropological led team including social scientists, political theorists, epidemiologists, and modellers. The team is based at the London School of Hygiene and Tropical Medicine with collaborations at University of Oxford, Anthrologica and the College of Medicine and Allied Health Sciences (University of Sierra Leone), Sierra Leone Urban Research Centre (SLURC), Centre for Applied Policy Research and Innovation Sierra Leone (CAPRI), and Conservation Through Public Health (CTPH) (African collaborations). Working in an innovative cross-disciplinary approach we address two public health problems: violence (structural and interpersonal) and epidemics (HIV, Ebola and COVID-19) and the intersections between them.

Our work draws on debates in the anthropology of epidemics and humanitarian emergencies; social science perspectives on medical research; anthropology of violence within conceptual framing of the future (uncertainty, hope, destiny, anticipation) and of power (structure, agency, bio-citizenship). We argue for the importance of anthropological perspectives in interventions to reduce violence and in biomedical responses to epidemics (including clinical trials and medical humanitarian response). We are at the forefront of debates on the importance of engaging with beneficiaries in the development and conduct of public health research.

Website - www.lshtm.ac.uk/research/centres-projects-groups/pave

The ESRC-funded Centre for Public Authority and International Development is based at the LSE and explores how governance works in marginalised and conflict-affected regions. It investigates the complexity of public authority and the risks and opportunities this creates for international development and inclusive growth (add link)

Melissa Parker’s contributions to this multi-disciplinary and collaborative project includes on-going research about: (i) Ebola and public authority (ii) COVID-19, public authority and enforcement and (iii) the various ways in which day to day experiences of child soldiers returning from the Lord’s Resistance Army in northern Uganda are shaped by formal, hybrid and informal public authorities.

Resources and publications

Parker, M., MacGregor, H and Akello, G 2020. COVID-19, public authority and enforcement. Medical Anthropology. https://doi.org/10.1080/01459740.2020.1822833

Allen, T., Atingo, J., Atim, D., Ocitti, J., Brown, C., Torre,C., Fergus, C. and Parker, M. 2020. What happened to children who returned from the Lord’s Resistance Army in Uganda. Journal of Refugee Studies

Torre, C., Mylan, S., Parker, M and Allen, T 2020. Is promoting war trauma a good idea?Anthropology Today 35 (6): 3-6.

Parker, M., Hanson, T., Vandi, A., Babawo, L and Allen, T 2019. Ebola and public authority: saving loved ones in Sierra Leone. Medical Anthropology 38 (5): 440-454.

Parker, M., Hanson, T.M., Vandi, A., Babawo, L.S. and Allen, T. 2019. Ebola, community engagement, and saving loved ones. The Lancet, published online on June 10^th at: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2819%2931364-9

McKay, G and Parker M, (2018). ‘Epidemics’ In:  Humanitarianism: A Dictionary of Concepts, pp: 81-95. Edited by T. Allen, Macdonald, A and Radice H. London/New York: Routledge

Overall Project Summary

Skin disease is a leading cause of global chronic disease burden and morbidity in low-resource settings. Neglected tropical diseases (NTDs) of the skin, such as Buruli ulcer, cutaneous leishmaniasis, leprosy, and yaws, are often associated with physical disability, psychological distress, social exclusion, and financial hardship. In communities affected by skin NTDs, there is also an enormous burden of other more common skin diseases, which may also be associated with stigma and reduced quality of life and may confound the diagnosis of skin NTDs.

The Skin Health Africa Research Programme (SHARP) aims to identify strategies for improving experiences of severe and stigmatizing skin NTDs through three interlinked research projects. Funded by the National Institute for Health Research, SHARP is a 4-year (2019-2023), multi-disciplinary, multi-institutional collaboration to conduct research in Ghana and Ethiopia.

Social Science

The SHARP social science team’s main role is to contribute to the development and evaluation of integrated case finding and management strategies for skin NTDs in Ghana and Ethiopia. The research seeks to understand deeply the role of local context to inform the design of the strategies, and to understand the intervention’s implementation and its impact on improving health and well-being outcomes in affected people and communities.

In particular, the team is exploring:

• the local care system for SSSDs, within and beyond health facilities, including households, lay people, faith and traditional healers, and private providers;
• the experiences of case detection and ‘illness’ among people affected by skin NTDs - including affected children - and their caregivers;
• stigma as a multi-layered phenomenon and its implications for case finding, control and management, and quality of life.

SHARP also includes training (MSc and PhD students) and other junior staff posts in Ghana and Ethiopia in order to develop social science research skills in the field of skin NTDs.

Methods include participant observation, interviews and focus group discussions.

People

The SHARP social science team includes:

• Collins Ahorlu, Noguchi Memorial Institute for Medical Research, Ghana
• Eric Koka, University of Cape Coast, Ghana
• Mirgissa Kaba Serbessa, School of Public Health, Addis Ababa University, Ethiopia
• Jennifer Palmer, LSHTM, UK
• Maria Zuurmond, LSHTM, UK

• Tara Mtuy, LSHTM, UK

Achieving the next big step in management of the HIV epidemic requires research and intervention development which not only engages with the structural factors that influence the spread of HIV, but also targeted approaches to facilitate access to health and social services.  Janet Seeley and colleagues, including Rachel King (UCSF), Suzanna Francis and Helen Weiss in EPH, have undertaken a number of studies with women at high risk for HIV infection in Kampala, Uganda and, Janet with Andrew Ssemata, Sarah Nakamanya and other Ugandan colleagues have been working with fisherfolk around Lake Victoria.  In addition, Martin Mbonye, a THRIVE fellow has been pursuing his PhD (supervised by Godfrey Siu and Janet Seeley) with men in long term relationships with sex workers in Kampala.

Studies

A cognitive behavioural and structural HIV prevention intervention for young Ugandan women engaging in high risk sexual behaviour (ZETRA) (PI Rachel King, UCSF)

A randomized controlled trial (RCT) testing the effectiveness of a combination structural and cognitive-behavioural prevention intervention for HIV-uninfected women aged 15 to 24 years who engage in high risk sexual activity. The intervention focuses on repeat HIV testing and counselling every 6 months, and increasing and sustaining sexual risk reduction behaviours to reduce STIs, HIV, and unplanned pregnancy. We have had three linked components that address both individual and structural factors affecting health care use as well as sexual behaviour and reproductive health decision-making: 1) peer group sessions that include alternative livelihood options and mentoring, 2) networking and reinforcement of healthy behaviuor using mobile technology, and 3) individual cognitive behavioural counselling by a trusted adult. We enrolled 614 HIV-uninfected women age 15- 24 years who engage in high risk sexual activity in Kampala. Half randomised to the intervention arm.  We followed the women for 18 months to assess frequency of unprotected sex (primary outcome), repeat HIV testing, unmet need for family planning, incidence of STIs including HIV, incidence of unintended recurrent pregnancies, and retention in care up to 18 months post-enrolment (secondary outcomes).

Masculinity and Health Seeking Behaviours of Regular Male Partners of Female Sex Workers in Kampala, Uganda (Martin Mbonye’s PhD project)

The main objective of the study has been to explore how certain constructs of masculinity influence health seeking among intimate male sexual partners of female sex workers in Kampala, Uganda.  Martin is investigating how long-term male sexual partners of female sex workers perceive their position as men within the context of a relationship in which they share their partners with others; exploring how the construction of masculinity by non-commercial male sexual partners of FSW presents barriers and opportunities for access to HIV prevention and care services and assessing how female sex workers, make sense of their relationships with their non-commercial male sexual partners and what influence they have in their sexual partners’ uptake of HIV services.  Martin has conducted an ethnographic study with 13 men, all of whom are in long term relationships with women who continue to sell sex to other men, in Kampala, Uganda.