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Reidpath DD, Allotey P, Barker SF, Clasen T, French M, Leder K, Ramirez-Lovering D, Rhule ELM, Siri J. Implementing "from here to there": A case study of conceptual and practical challenges in implementation science. Soc Sci Med 2022; 301:114959. [PMID: 35398672 DOI: 10.1016/j.socscimed.2022.114959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 11/27/2022]
Abstract
There is a significant challenge in global health and development research that pivots on the difficulties of delivering (cost-)effective treatments or interventions that are scalable andtransferable across settings. That is, how does one deliver "true effects", proven treatments, into new settings? This is often addressed in pragmatic trials or implementation research in which one makes adjustments to the delivery of the treatment to ensure that it works here and there. In this critical analytical review, we argue that the approach mis-characterises the cause-effect relationship and fails to recognise the local, highly contextual nature of what it means to say an intervention "works". We use an ongoing randomised controlled trial (RCT)-an informal settlement redevelopment intervention in Indonesia and Fiji to reduce human exposure to pathogenic faecal contamination-as a vehicle for exploring the ideas and implications of identifying interventions that work in global health and development. We describe the highly contextualised features of the research and the challenges these would pose in attempts to generalise the results. In other words, we detail that which is frequently elided from most RCTs. As our critical lens, we us the work of American philosopher, Nancy Cartwright, who argued that research produces dappled regions of causal insights-lacunae against a backdrop of causal ignorance. Rather than learn about a relationship between a treatment and an outcome, we learn that in the right sort of context, a treatment reliably produces a particular outcome. Moving a treatment from here to there becomes, therefore, something of an engineering exercise to ensure the right factors (or "shields") are in place so the cause-effect is manifest. As a consequence, one cannot assume that comparative effectiveness or cost-effectiveness would be maintained.
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Affiliation(s)
- Daniel D Reidpath
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh; Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Sunway, Malaysia.
| | - Pascale Allotey
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Sunway, Malaysia; International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - S Fiona Barker
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Thomas Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Matthew French
- Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Karin Leder
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Diego Ramirez-Lovering
- Faculty of Art, Design and Architecture, Monash University, Caulfield, Victoria, Australia
| | - Emma L M Rhule
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - José Siri
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
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French MA, Fiona Barker S, Taruc RR, Ansariadi A, Duffy GA, Saifuddaolah M, Zulkifli Agussalim A, Awaluddin F, Zainal Z, Wardani J, Faber PA, Fleming G, Ramsay EE, Henry R, Lin A, O'Toole J, Openshaw J, Sweeney R, Sinharoy SS, Kolotelo P, Jovanovic D, Schang C, Higginson EE, Prescott MF, Burge K, Davis B, Ramirez-Lovering D, Reidpath D, Greening C, Allotey P, Simpson JA, Forbes A, Chown SL, McCarthy D, Johnston D, Wong T, Brown R, Clasen T, Luby S, Leder K. A planetary health model for reducing exposure to faecal contamination in urban informal settlements: Baseline findings from Makassar, Indonesia. Environ Int 2021; 155:106679. [PMID: 34126296 DOI: 10.1016/j.envint.2021.106679] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The intense interactions between people, animals and environmental systems in urban informal settlements compromise human and environmental health. Inadequate water and sanitation services, compounded by exposure to flooding and climate change risks, expose inhabitants to environmental contamination causing poor health and wellbeing and degrading ecosystems. However, the exact nature and full scope of risks and exposure pathways between human health and the environment in informal settlements are uncertain. Existing models are limited to microbiological linkages related to faecal-oral exposures at the individual level, and do not account for a broader range of human-environmental variables and interactions that affect population health and wellbeing. METHODS We undertook a 12-month health and environmental assessment in 12 flood-prone informal settlements in Makassar, Indonesia. We obtained caregiver-reported health data, anthropometric measurements, stool and blood samples from children < 5 years, and health and wellbeing data for children 5-14 years and adult respondents. We collected environmental data including temperature, mosquito and rat species abundance, and water and sediment samples. Demographic, built environment and household asset data were also collected. We combined our data with existing literature to generate a novel planetary health model of health and environment in informal settlements. RESULTS Across the 12 settlements, 593 households and 2764 participants were enrolled. Two-thirds (64·1%) of all houses (26·3-82·7% per settlement) had formal land tenure documentation. Cough, fever and diarrhoea in the week prior to the survey were reported among an average of 34.3%, 26.9% and 9.7% of children aged < 5 years, respectively; although proportions varied over time, prevalence among these youngest children was consistently higher than among children 5-14 years or adult respondents. Among children < 5 years, 44·3% experienced stunting, 41·1% underweight, 12.4% wasting, and 26.5% were anaemic. There was self- or carer-reported poor mental health among 16.6% of children aged 5-14 years and 13.9% of adult respondents. Rates of potential risky exposures from swimming in waterways, eating uncooked produce, and eating soil or dirt were high, as were exposures to flooding and livestock. Just over one third of households (35.3%) had access to municipal water, and contamination of well water with E. coli and nitrogen species was common. Most (79·5%) houses had an in-house toilet, but no houses were connected to a piped sewer network or safe, properly constructed septic tank. Median monthly settlement outdoor temperatures ranged from 26·2 °C to 29.3 °C, and were on average, 1·1 °C warmer inside houses than outside. Mosquito density varied over time, with Culex quinquefasciatus accounting for 94·7% of species. Framed by a planetary health lens, our model includes four thematic domains: (1) the physical/built environment; (2) the ecological environment; (3) human health; and (4) socio-economic wellbeing, and is structured at individual, household, settlement, and city/beyond spatial scales. CONCLUSIONS Our planetary health model includes key risk factors and faecal-oral exposure pathways but extends beyond conventional microbiological faecal-oral enteropathogen exposure pathways to comprehensively account for a wider range of variables affecting health in urban informal settlements. It includes broader ecological interconnections and planetary health-related variables at the household, settlement and city levels. It proposes a composite framework of markers to assess water and sanitation challenges and flood risks in urban informal settlements for optimal design and monitoring of interventions.
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Affiliation(s)
- Matthew A French
- Monash Sustainable Development Institute, Monash University, Victoria 3800, Australia
| | - S Fiona Barker
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004, Australia
| | - Ruzka R Taruc
- RISE Program, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
| | | | - Grant A Duffy
- School of Biological Sciences, Monash University, Victoria 3800, Australia
| | | | | | - Fitriyanty Awaluddin
- RISE Program, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Zainal Zainal
- RISE Program, Faculty of Public Health, Hasanuddin University, Makassar, Indonesia
| | - Jane Wardani
- Monash Sustainable Development Institute, Monash University, Victoria 3800, Australia
| | - Peter A Faber
- School of Biological Sciences, Monash University, Victoria 3800, Australia
| | - Genie Fleming
- School of Biological Sciences, Monash University, Victoria 3800, Australia
| | - Emma E Ramsay
- School of Biological Sciences, Monash University, Victoria 3800, Australia
| | - Rebekah Henry
- Environmental and Public Health Microbiology Laboratory (EPHM Lab), Department of Civil Engineering, Monash University, Victoria 3800, Australia
| | - Audrie Lin
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Joanne O'Toole
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004, Australia
| | - John Openshaw
- Woods Institute and the Freeman Spogli Institute, Stanford University, Stanford, CA 94305, USA
| | - Rohan Sweeney
- Centre for Health Economics, Monash Business School, Monash University, Victoria 3145, Australia
| | - Sheela S Sinharoy
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Peter Kolotelo
- Environmental and Public Health Microbiology Laboratory (EPHM Lab), Department of Civil Engineering, Monash University, Victoria 3800, Australia
| | - Dusan Jovanovic
- Environmental and Public Health Microbiology Laboratory (EPHM Lab), Department of Civil Engineering, Monash University, Victoria 3800, Australia
| | - Christelle Schang
- Environmental and Public Health Microbiology Laboratory (EPHM Lab), Department of Civil Engineering, Monash University, Victoria 3800, Australia
| | - Ellen E Higginson
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Michaela F Prescott
- Informal Cities Lab, Monash Art Design & Architecture, Monash University, Victoria 3145, Australia
| | - Kerrie Burge
- Monash Sustainable Development Institute, Monash University, Victoria 3800, Australia
| | - Brett Davis
- Monash Sustainable Development Institute, Monash University, Victoria 3800, Australia
| | - Diego Ramirez-Lovering
- Informal Cities Lab, Monash Art Design & Architecture, Monash University, Victoria 3145, Australia
| | - Daniel Reidpath
- The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh; Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Chris Greening
- Biomedicine Discovery Institute, Department of Microbiology, Monash University, Victoria 3800, Australia
| | - Pascale Allotey
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia; International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004, Australia
| | - Steven L Chown
- School of Biological Sciences, Monash University, Victoria 3800, Australia
| | - David McCarthy
- Environmental and Public Health Microbiology Laboratory (EPHM Lab), Department of Civil Engineering, Monash University, Victoria 3800, Australia
| | - David Johnston
- Centre for Health Economics, Monash Business School, Monash University, Victoria 3145, Australia
| | - Tony Wong
- Water Sensitive Cities Institute, Monash University, Victoria 3800, Australia
| | - Rebekah Brown
- Monash Sustainable Development Institute, Monash University, Victoria 3800, Australia
| | - Thomas Clasen
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - Stephen Luby
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Karin Leder
- School of Public Health and Preventive Medicine, Monash University, Victoria 3004, Australia.
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Leder K, Openshaw JJ, Allotey P, Ansariadi A, Barker SF, Burge K, Clasen TF, Chown SL, Duffy GA, Faber PA, Fleming G, Forbes AB, French M, Greening C, Henry R, Higginson E, Johnston DW, Lappan R, Lin A, Luby SP, McCarthy D, O'Toole JE, Ramirez-Lovering D, Reidpath DD, Simpson JA, Sinharoy SS, Sweeney R, Taruc RR, Tela A, Turagabeci AR, Wardani J, Wong T, Brown R. Study design, rationale and methods of the Revitalising Informal Settlements and their Environments (RISE) study: a cluster randomised controlled trial to evaluate environmental and human health impacts of a water-sensitive intervention in informal settlements in Indonesia and Fiji. BMJ Open 2021; 11:e042850. [PMID: 33419917 PMCID: PMC7798802 DOI: 10.1136/bmjopen-2020-042850] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Increasing urban populations have led to the growth of informal settlements, with contaminated environments linked to poor human health through a range of interlinked pathways. Here, we describe the design and methods for the Revitalising Informal Settlements and their Environments (RISE) study, a transdisciplinary randomised trial evaluating impacts of an intervention to upgrade urban informal settlements in two Asia-Pacific countries. METHODS AND ANALYSIS RISE is a cluster randomised controlled trial among 12 settlements in Makassar, Indonesia, and 12 in Suva, Fiji. Six settlements in each country have been randomised to receive the intervention at the outset; the remainder will serve as controls and be offered intervention delivery after trial completion. The intervention involves a water-sensitive approach, delivering site-specific, modular, decentralised infrastructure primarily aimed at improving health by decreasing exposure to environmental faecal contamination. Consenting households within each informal settlement site have been enrolled, with longitudinal assessment to involve health and well-being surveys, and human and environmental sampling. Primary outcomes will be evaluated in children under 5 years of age and include prevalence and diversity of gastrointestinal pathogens, abundance and diversity of antimicrobial resistance (AMR) genes in gastrointestinal microorganisms and markers of gastrointestinal inflammation. Diverse secondary outcomes include changes in microbial contamination; abundance and diversity of pathogens and AMR genes in environmental samples; impacts on ecological biodiversity and microclimates; mosquito vector abundance; anthropometric assessments, nutrition markers and systemic inflammation in children; caregiver-reported and self-reported health symptoms and healthcare utilisation; and measures of individual and community psychological, emotional and economic well-being. The study aims to provide proof-of-concept evidence to inform policies on upgrading of informal settlements to improve environments and human health and well-being. ETHICS Study protocols have been approved by ethics boards at Monash University, Fiji National University and Hasanuddin University. TRIAL REGISTRATION NUMBER ACTRN12618000633280; Pre-results.
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Affiliation(s)
- Karin Leder
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - John J Openshaw
- Infectious Diseases and Geographic Medicine Division, Stanford University, Stanford, California, USA
| | - Pascale Allotey
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - Ansariadi Ansariadi
- Public Health Faculty, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia
| | - S Fiona Barker
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Kerrie Burge
- CRC for Water Sensitive Cities, Monash University, Melbourne, Victoria, Australia
| | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Steven L Chown
- School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Grant A Duffy
- School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Peter A Faber
- School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Genie Fleming
- School of Biological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Matthew French
- Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Chris Greening
- Department of Microbiology, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Rebekah Henry
- Civil Engineering, Monash University, Melbourne, Victoria, Australia
| | - Ellen Higginson
- Cambridge Institute for Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - David W Johnston
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia
| | - Rachael Lappan
- Department of Microbiology, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Audrie Lin
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Stephen P Luby
- Infectious Diseases and Geographic Medicine Division, Stanford University, Stanford, California, USA
| | - David McCarthy
- Civil Engineering, Monash University, Melbourne, Victoria, Australia
| | - Joanne E O'Toole
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Daniel D Reidpath
- Monash University - Malaysia Campus, Bandar Sunway, Selangor, Malaysia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Sheela S Sinharoy
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Rohan Sweeney
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia
| | - Ruzka R Taruc
- Public Health Faculty, Hasanuddin University, Makassar, Sulawesi Selatan, Indonesia
| | - Autiko Tela
- School of Public Health and Primary Care, Fiji National University, College of Medicine, Nursing and Health Sciences, Tamavua Campus, Suva, Rewa, Fiji
| | - Amelia R Turagabeci
- School of Public Health and Primary Care, Fiji National University, College of Medicine, Nursing and Health Sciences, Tamavua Campus, Suva, Rewa, Fiji
| | - Jane Wardani
- Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Tony Wong
- CRC for Water Sensitive Cities, Monash University, Melbourne, Victoria, Australia
| | - Rebekah Brown
- Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
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French M, Ramirez-Lovering D, Sinharoy SS, Turagabeci A, Latif I, Leder K, Brown R. Informal settlements in a COVID-19 world: moving beyond upgrading and envisioning revitalisation. ACTA ACUST UNITED AC 2020. [PMCID: PMC7484572 DOI: 10.1080/23748834.2020.1812331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The COVID-19 pandemic represents a turning point in the way things are done, globally and
across sectors. We reflect on approaches to informal settlements and argue for a turn from
‘upgrading’ to ‘revitalisation’. We conceptualise revitalisation as encompassing three
core tenets: planetary health, transdisciplinarity, and a people-centred approach. In our
vision, revitalisation approaches would take a big-picture view of informal settlements
that recognises the inter-connectedness of people and nature within complex urban systems;
integrates perspectives from various academic disciplines, non-academic sectors, and
communities for knowledge generation; and centres informal settlement residents and
communities as experts and partners in urban praxis.
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Affiliation(s)
- Matthew French
- Monash Sustainable Development Institute, Monash University, Melbourne, Australia
| | | | - Sheela S. Sinharoy
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Amelia Turagabeci
- Department of Epidemiology & Environmental Health, Fiji National University, Suva, Fiji
| | - Ihsan Latif
- Department of City and Regional Development, Universitas Hassanudin, Makassar, Indonesia
| | - Karin Leder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rebekah Brown
- Office of the Provost and Senior Vice-President, Monash University, Melbourne, Australia
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