GVHC Leadership change announcement

The Gender Violence and Health Centre (GVHC) would like to thank Dr. Lori Heise for her dedicated and creative leadership in the past years. Dr. Heise has continually offered inspirational guidance to GVHC members, colleagues and students at LSHTM and partners around the world, and we are pleased that, although she is transferring to Johns Hopkins University, she we will remain a part of the Centre.

We are also extremely happy to announce that Dr. Heidi Stöckl and Dr. Ana Maria Buller are taking over as the new Director and Deputy Director of GVHC. Their leadership transition is supported by Professors Charlotte Watts, Lori Heise and Cathy Zimmerman, who founded and led GVHC in the past and will continue their involvement in the Centre’s work. 

As the new Director and Deputy Director, Heidi and Ana Maria hope to continue working closely with our current partners, as well as develop new partnerships and continue producing cutting edge evidence to prevent and respond to gender-based violence.

The GVHC thanks everyone for their past support and looks forward to many years of future collaboration with our partners around the world.

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Injecting a business perspective into routine immunization programs

by Christian Suharlim (Harvard T.H. Chan School of Public Health)

Cross-posted at immunizationeconomics.org.

Imagine you own a parking garage business. Half of your costs are associated with owning, building, and maintaining the property – a third for labor costs associated with managing the operations – and the rest for promotional materials, security, and insurance. Businesses often maintain detailed information on the cost structure of their operations. They use this information to help them better allocate resources, identify more efficient ways of operating, and ultimately free up funds for business expansion or profit.

However, the use of such methods to analyze public health services is less common.

In a new study published in Health Policy and Planning, a research team from the Harvard T.H. Chan School of Public Health examined the cost structure of routine immunization programs in six countries. These were Benin, Ghana, Honduras, Moldova, Uganda and Zambia.

They found that 77-93% of the total cost of immunization program was attributable to the healthcare facility. The remaining costs were primarily associated with logistical and administrative costs at the national and subnational health offices. Further unpacking the facility-level costs, they found that 63% of these costs were associated with immunization delivery via facility-based service or outreach service, with the remaining 37% spent on supply chain, program management, social mobilization, monitoring and evaluation.

Lead author Fangli Geng shared major takeaways from the findings. “We found that labor costs were a key driver of the facility-level delivery costs.  When we compare more and less efficient sites, we find that labor costs explain a lot of this difference. At the moment, we’re exploring to what extent these costs are explained by contextual factors such as geographical barriers or improved quality,” she said.

“Management and administrative activities account for about a third of facility-level delivery costs.” Geng continued. “Innovations that make these activities more efficient could free up substantial resources to provide better services for underserved populations, such as those in geographically remote areas and the socially marginalized.”

This study comes at a time where novel methods are being piloted in the field of immunization delivery. In October of last year, Gavi partnered with UPS and Zipline to use drone technology to deliver blood supplies to health clinics in Rwanda. This drone-assisted blood supplies delivery serve as a test for other health purposes, including vaccine delivery. Similarly, pilot projects utilizing mobile phones (M-Health) such as text reminders for immunization programs have been well received in low-and-middle income county settings. These novel approaches will add to the toolbox for improving social mobilization.

Geng’s research is part of a larger project called EPIC – Expanded Program on Immunization Costing, Financing, and Efficiency, led by the Harvard T.H. Chan School of Public Health.

“One major goal for EPIC is to figure out how to routinely collect cost data – so that immunization managers can perform these kinds of cost structure analysis real-time and make optimal resource allocation decisions,” noted Stephen Resch, principal investigator of the EPIC project and the deputy director of Harvard’s Center for Health Decision Science.

This research adds to the understanding of the detailed cost structure and site-efficiency of routine immunization programs, further understanding of the site-level characteristics could reveal approaches to improve efficiency and performance of immunization delivery sites. Comprehensive resources for researchers and policy makers associated with this research and the EPIC project are available on their website, immunizationeconomics.org.

“The cost structure of routine infant immunization services: a systematic analysis of six countries,” Fangli Geng, Christian Suharlim, Logan Brenzel, Stephen C Resch, and Nicolas A Menzies, Health Policy and Planning, online May 31, 2017, doi: 10.1093/heapol/czx067

Image credit: PATH Global Health

Ending AIDS by 2030 means removing bottlenecks to care and treatment – supplement and blog post now online

Contextual, social and health system factors influence how people with HIV engage with care and treatment in sub-Saharan Africa – but how?  The ‘Bottlenecks’ study published in the journal Sexually Transmitted Infections has provided crucial insight. Funded by the Bill & Melinda Gates Foundation, the multi-country qualitative study examined the bottlenecks to HIV care and treatment at seven sites in six African countries; Kenya, Uganda, Tanzania, Malawi, South Africa and Zimbabwe.

Read the full blog post by Dr. Jenny Renju, Assistant Professor of Epidemiology, here


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11 – 24 July 2017

Following Prince Harry’s visit to the School, Peter Piot and Sentebale CEO Catherine Ferrier co-write a blog for the Huffington Post calling for the voices of young people affected by HIV/AIDS to be heard: “The largest ever generation of adolescents in sub-Saharan Africa is at risk of HIV, many of these young people are failing to test for the virus and access the relevant follow-up care and treatment… and the world is not listening to them.”

Val Curtis writes for the Indian Express on the importance of India’s goal of ending open defecation by October 2019. “It has long been known that lack of toilets allows faecal germs to spread, which cause sometimes fatal illnesses like cholera and diarrhoea, especially among children.”

Healio cover news that a new type of long-lasting insecticide treated bed net developed by BASF in collaboration with the School, with the support of Innovative Vector Control Consortium, has received recommendation for use by the World Health Organization. Over 80 outlets cover the story including Pakistan Observer, African Review, Medical ExpressNews-Medical and The Standard (Kenya).

Heidi Larson speaks to The Verge about the proposed law in France that would make 11 vaccines mandatory for children: “It’s one of these decisions that, if it’s well managed, could be helpful. If it’s very top-down, it could totally backfire.” Heidi is also interviewed by Le Monde.

SciDev.net report on a study co-authored by the School that demonstrates how WhatsApp is being used in Syria to help monitor and collect data on attacks on healthcare workers.

HansIndia report on Rachel Lowe’s recent study that used climate forecasts to predict the risk of a dengue epidemic in the coastal city of Machala, Ecuador.

Sally Bloomfield is quoted in a Daily Mail article that asks if having a washing machine in the kitchen is a hygiene hazard. “Dirty laundry is still an important part in the hygiene picture.”



Collaborative and Co-funded studentship competition now open for applications

This competition invites academics, in collaboration with non-academic partners, to submit proposals for studentship projects to begin October 2018. Collaboration partners must be non-academic organisations with an operating base in the UK – they can be private, public or voluntary sector organisations.

The application will need to be completed jointly with the collaborative partners, including a project proposal and outlining the collaborative arrangements between the two. The deadline for applications is Thursday 30 November 2017

For more information, and the application form and guidance notes, please go to https://ubel-dtp.ac.uk/co-funded-collaborative-studentships-2018-entry/

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Congratulations to Dr. Nicola Pocock

We are very pleased to welcome Dr. Nicola Pocock as a new member the post-doctoral scholar community. Dr. Pocock passed her PhD viva examinations on 14th July 2017, with no changes required.

Dr Pocock’s seminal work on human trafficking for commercial fishing and health was co-supervised by GVHC staff members, Cathy Zimmerman, Ligia Kiss, Heidi Stoeckl and by Fiona Adamson of SOAS. Dr. Pocock’s PhD research was the first major study of health and wellbeing of labour trafficked men and boys for fishing. Her work contributed substantially to evidence that human trafficking is not limited to women and girls. She explored the very under studied subject of victim identification and assistance, labour inspections, drawing on research with diverse range of stakeholders in Thailand. Her findings raised questions about risk and protective factors (e.g., documents weren’t protective for injuries or violence) and was the first empirical analysis of this question among this population.

Nicola will be undertaking a post-doctoral position with the United Nations University in Kuala Lumpur, Malaysia, starting in August.


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Peek demo for Prince Harry


During a visit to the London School of Hygiene & Tropical Medicine, he met Peek co-founder and CEO Andrew Bastawrous, who is also Assistant Professor in International Eye Health at the School, along with other members of the Peek team including members from India and Botswana.

Andrew explained how Peek’s School Eye Health Programmes work and the problems they seek to solve of young children not reaching their potential because they can’t see properly. He also showed the Prince the Peek Acuity app and Peek Retina in action.

Prince Harry was at LSHTM for a special roundtable discussion on HIV/AIDS in his role as Co-Founding Patron of the charity Sentebale. Global HIV leaders and researchers heard first-hand from youth advocates from Botswana and Lesotho and committed to ensuring young people affected by HIV/AIDS play an integral part in shaping new research and policies to strengthen prevention, testing and treatment in sub-Saharan Africa.

Before the meeting, His Royal Highness joined School Director Professor Peter Piot on a tour to meet researchers investigating and working to find solutions to a number of health challenges including the Peek team.

Andrew said: “It was an honour to have the opportunity to talk to Prince Harry about Peek. He has spent a lot of time in Botswana and was particularly interested in the progress we are making on delivering a national school eye health programme with our partners.”

The Earl and Countess of Wessex have previously been shown and used Peek.

Photo: Prince Harry watches Andrew Bastawrous demonstrate how Peek works on Sarah O’Regan during visit to LSHTM. Credit: Getty Images/Chris Jackson for LSHTM

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“Rethink questions to patients in general practice and focus more on improving primary care”

By Tommaso Manacorda

The “Friends and Family Test”, seeking patients’ views, has created anxiety among practices but shed little light on patients’ concerns. It’s time for a rethink, suggests our study.

The many ways in which patients can now feedback to GPs should offer a rich source of information for those keen to improve their services. However, when we evaluated the latest addition to patient consultation in England – the “Friends and Family Test” of patient satisfaction – we found that “more” did not necessarily equate with “better”.

We found that general mistrust of the FFT process, combined with inappropriate framing of its core question is undermining the initiative. But we also identified ways both to bolster trust and make patient feedback more useful for improving primary care.

Two important pieces of learning emerge from examining this initiative. First, the issues raised by the “Friends and Family Test” could usefully prompt a rethink about how views are gathered from patients about their primary care experiences. Our main recommendation is that the FFT should be revised, although discontinuing it should also be considered, as its reception within general practice has been largely negative.

Second, GPs need more encouragement and guidance to tackle inadequacies revealed by patients’ experience. We found that commitment to quality improvement is uneven across primary care and remains a low priority in some, often in those practices where patient participation groups (PPGs) meet rarely and patient surveys are infrequently conducted. Nurturing a rigorous improvement culture is at least as important as getting right the questions posed to patients.

Wording of the FFT
The “Friends and Family Test” puts a single question to patients about their general practice: “We would like you to think about your recent experience of service. How likely are you to recommend our GP practice to friends and family if they needed similar care and treatment?” Answers are recorded on a five point scale from “extremely likely” to “extremely unlikely”. Additionally, patients may be asked to comment on their reasons for the score they have given.

General practices across the NHS are required to make the FFT available to patients after every contact, collecting the data with the method that suits them best. The majority of them use handwritten cards, but tablet kiosks and online apps are also used.

Our evaluation, involving 42 practices and 118 interviews with clinicians, practice staff and patients’ representatives, found two sets of problems with the FFT. The first concerned the usefulness of the information it produced. The second problem lay with how general practices understood the FFT’s purpose and how they engaged with it.

The experiences of hospitals, where the FFT was first introduced, showed that the quantitative scores were statistically unreliable. So the metrics could not be used to compare providers for quality. That’s because the FFT does not involve a representative sample and is vulnerable to selection bias. One can’t tell whether the scores are representative of all patients. So, when the FFT question was subsequently rolled out in 2014 into primary care, the widespread awareness of these statistical limitations contributed to unease in general practices about the FFT approach.

In our study, the FFT question was deemed inappropriate by most interviewees. Many, particularly in rural areas, lacked choice of general practice, so the question of where they might send friends or family lacked reality. Also, patients found it difficult to compare their personal care with what someone else might receive, because that depends on individual factors such as age, sex and existing health conditions. Most interviewees suggested the use of a more straightforward question.

The additional space provided for further comment did potentially offer some useful feedback. However, staff in general practices felt that the anonymity of patients made it difficult to act on these comments. That’s because patients were often unclear which service they had received, from whom and the precise nature of issue that concerned them. For example, a patient complained about a “terrible phone service”. But staff said it was difficult to respond to this statement because they didn’t know who the complainant was, whom the patient had spoken to or what they needed.

Most patient feedback collected by practices was positive, but anonymity and vagueness made it difficult to identify and reward good practice. Positive feedback would often lift staff morale. However, the inability to act on complaints was often reported to be very frustrating for staff.

When additional comments gathered by the FFT pointed at some specific issues, their contribution was still considered to be of little value because the issues were already known to staff from other sources, such as practice surveys and patient participation groups.

Professionals mistrust the process
The second issue with the FFT concerned the negative reception that it received from primary care professionals. Some feared that it left them vulnerable to hostile patients. Someone might, for example, be correctly denied an antibiotic for sound clinical reasons but then score down the practice unfairly. The practice would have no way to question the scoring.

Monthly reporting of scores to the DH and NHSE added to professional concerns that the FFT process was, as some claimed, “a stick with which to beat General Practice”. Even though the Government had stated that it would not use FFT scores to rank practices, that fear of unfairness remained unassuaged, which disheartened hard-working professionals.

As a result, although all the practices in our evaluation had made the FFT available to patients, few practices felt committed to, or “owned”, the process. Even though practices had been assured that the test was intended for local quality improvement, not regulation (or criticism) by national bodies, they remained doubtful, particularly because of the monthly reporting. One GP, not realising that the scores were for meant for practice consumption, even asked their practice manager during a joint interview: “Do we have to open the box?”

Shift to reporting quality improvements
We recommend that monthly reporting of FFT scores should be stopped, and maybe replaced by a qualitative report on local quality improvements, perhaps submitted annually. That would help restore trust among practices that central bodies are not “spying” on them.

Particularly valuable aspects of the FFT are the chance for patients to comment briefly and quickly about their experiences, and the opportunity for practices to collect such feedback rapidly and easily. This comment facility could, for example, be kept within an FFT that had a less confusing core question, and patients could be encouraged to be more specific about particular services (e.g. phone consultations, clinics for chronic diseases, immunisation, etc.), making it easier to identify and address problems on aspects of care that they want to be improved.

The key issue in the long-term will be whether, and to what extent, patients’ views will contribute to making services better. Commitment to quality improvement was found to be uneven across practices. A revised FFT might play an useful role in addressing this problem, being easy to implement and thus a feasible option particularly for smaller practices with less capacity for data collection. But extra detailed guidance is needed on how to ensure that patient feedback leads to service improvement. It will be important to make clear that the Government’s priority is aligned with that of GPs in being focussed on securing higher quality primary care.

Tommaso Manacorda is a Research Fellow at the London School of Hygiene and Tropical Medicine. His report “Implementation and use of the Friends and Family as a tool for local service improvement in NHS general practice in England” is published by PIRU and co-authored by Dr Bob Erens, Professor Sir Nick Black and Professor Nicholas Mays.

This commentary summarizes an independent report commissioned and funded by the Policy Research Programme of the Department of Health for England, via its core support for the Policy Innovation Research Unit, with additional funding provided for data collection from the main sample of general practices. The views expressed are those of the authors and not necessarily those of the Department.

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Climate change: looking beyond the environmental impact (part 2)

By Victoria Ponce, MARCH centre blog volunteer (MSc Public Health candidate)

This year’s climate change discussion and polemic have been accentuated by events such as the carbon dioxide peak in May, Portugal’s deadly wildfires and the hottest June day in England and Wales in more than 40 years. These events, and many others occurring around the world, show that, more than ever, it is urgent to discuss the impact of global warming on health and how it affects vulnerable groups.

This piece is the second of a three-part series on climate change and the health of women, children and adolescents. Here, we explore how climate change can impact the health and lives of children, one of the groups most affected by climate change.

Children’s health and climate change

According to UNICEF, children are the most vulnerable to the effects of climate change and are more likely to experience health problems or displacement as result of heat waves, droughts and floods.    

Because of their growth and development, children breathe more air than adults, need to eat and drink more than adults and have different behaviours and exposures than adults, but all the while are dependent on adults for their survival and have little to no control over their own environment.

These factors make children particularly susceptible to environmental exposures that are likely to increase in intensity under climate change, such as air pollution, temperature changes, disease vectors, and food and water supply. Because of their age, children also have the longest anticipated exposure to changes in the climate and environment and, consequently, are more vulnerable to long term health consequences of climate change.

But climate change does not affect all children equally; rather it intersects with existing vulnerabilities. This means that children who are already faced with poverty are the ones who will suffer the most immediate and devastating impacts of events like floods and droughts. The consequences of these events are exacerbated by the lack of resources or inability to cope, leaving children with a triple burden of risk, exposure and vulnerability.

A child, and by proxy their family, living in a high-income setting is more likely to have appropriate resources on hand to be able to cope with climate change than a child from a low-income setting. In this way, climate change may widen already deep inequalities in children’s health across the world.

Key health threats

Climate change is likely to affect and exacerbate some of the world’s leading causes of childhood mortality and morbidity. For example, changes in global temperature and precipitation patterns are expected to produce shifts in infectious disease patterns and geographical distribution of diseases such as malaria, dengue fever and meningococcal meningitis and children are likely to carry the burden of these changes.

Droughts and floods continuously contribute to a lack of clean water supplies as well as a decrease in food availability. These conditions can contribute to outbreaks of diarrhoeal disease, a leading cause of childhood mortality which is estimated to kill around 1.5 million children globally per year, and contribute to undernutrition in young children which can lead to severe developmental impacts later in life.

The increasing frequency of heatwaves in some regions is another point of concern when looking at children’s health. Due to their low capacity to adapt to changes in temperature and regulate their body temperature children are more likely to suffer from heat exhaustion, heat rash, cramps, stroke and dehydration, which can in turn lead to increased risk of hyperthermia.

Increases in temperature are also likely to exacerbate the effects of air pollution, which in turn poses a significant burden of attributable childhood mortality and morbidity. Warmer temperatures contribute to increases in ground-level ozone, which is associated with childhood asthma, as well as playing a role in increasing levels of ambient dust and pollen from forest fires, droughts, and changes in vegetation. Both indoor and outdoor air pollution have been linked to severe health outcomes for children, including low birth weight, acute lower respiratory infections, such as pneumonia, and higher risk of chronic respiratory and cardiovascular diseases.

Also, disturbingly, climate change is increasingly adding figures to the global number of children forced out of their homes and into precarious situations. Climate change-related migration or displacement often expose these children to psychological and emotional trauma, disrupted education and healthcare, and increases the chance of separation from their family. In addition, they might be affected by the health status of their parents or guardians and subjected to lack of food, water and security.

Children in the climate change agenda

Children and their health have not traditionally been a central focus of climate change policy. For example, while the Paris Climate Agreement (2015) set an optimistic tone for climate change policy in general, children and intergenerational equity are mentioned only briefly and children’s health is absent in the document. Children’s specific vulnerability to climate change is likewise not explicit within the 2015 Sustainable Development Goals.

Potentially most damaging to the integration of children’s rights into climate change policy is the USA’s President Trump’s recent withdrawal from the Paris Climate Change Agreement. Although this prompted a wave of condemnation from world leaders, a lack of US backing in the already uphill fight against climate change could have severe consequences globally, not least in countries most susceptible to the most immediate effects of climate change and where the majority of the world’s most vulnerable children reside.

On the bright side, organisations such as the UN, Plan International and Save the Children have been pushing for consideration of children’s health within climate change policy. In 2007, the Children in a Changing Climate (CCC) Coalition was established as a partnership of Save the Children, UNICEF, World Vision International, Plan International and the ChildFund Alliance. The CCC Coalition advocates and promotes the integration of children’s rights into climate change policy and practices.

More recently, in 2015, UNICEF outlined a ten-step agenda for the centralisation of children into the climate change policy arena, emphasising the risks to children’s health from climate change and the potential for children to contribute to and gain from better climate change policy.

Similarly, the WHO’s Global Plan of Action for Children’s Health and the Environment advocates for the inclusion of children’s health in climate change research agendas and policy movements. Grassroots movements, such as the 3rd International Climate Change Conference for Children, organised in 2016 in Uganda, shine a positive light on the potential for inclusion of children within climate change policy and practice. 

Children’s dependence on their wider environment makes them especially vulnerable to climate change-related health risks and in so many contexts related to climate change, they cannot speak or act for themselves. However, there does seem to be a rising effort from some organisations to empower and involve children in the climate change discussion.  

By making children central to climate change policy and by strengthening the resilience of the most vulnerable children, extensive damage to children’s health could be avoided and future generations could be equipped with the tools and knowledge necessary to mitigate and adapt further.

Image Copyright: http://www.savethechildren.org.au/our-work/program-selector/climate-change-adaptation – Children learning about climate change in Vanuatu

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