Bridging the gap for post-project evaluations of adolescent sexual and reproductive health projects: Guidance from WHO

By Susan Igras (Georgetown University’s Institute for Reproductive Health, Center for Child and Human Development), Marina Plesons (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the World Health Organization) and Venkatraman Chandra-Mouli (UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the World Health Organization)

Background

Well-designed program evaluation can lead to strong evidence that informs policies and future program planning. Yet, many of the projects and programs that aim to improve adolescent sexual and reproductive health (ASRH) in low- and middle-income countries are often implemented without well-thought-out plans for evaluation. This is equally true for other health and social development programming. In the absence of evaluation evidence, the lessons that programs learn encountering and addressing policy and programmatic challenges are often not extracted and placed in the public arena. The limited evaluations that use pre/post-intervention designs and whose findings are published, then, play an overly dominant role in guiding policy and program development thinking.

Post-project evaluation, which is designed and carried out after projects have ended, offers the possibility to generate learnings about what works (and doesn’t work) to complement prospective studies of new or follow-on projects to bring information and evidence on innovative interventions or approaches that appeared to work well into the public arena.

Guidance from the World Health Organization (WHO)

As outlined in the 2019 WHO Guidance, The project has ended, but we can still learn from it:  Practical Guidance for Post-Project Evaluation, evaluators must navigate a range of issues and challenges when conducting post-project evaluations, both contextual and methodological.  In a post-project context, project staff with historical knowledge may have moved to new projects and are no longer available to provide information and help interpret findings. Project operations have likely ended so are not observable by evaluators, and participants may no longer be easily contactable. Establishing a comparison group may be feasible, but requires careful forethought with the help of local stakeholders. The ageing of adolescents who were program participants complicates post-project impact assessment; thus, careful consideration is necessary to address maturation and consequent changes in adolescents’ cognition and other capacities and lived experiences in the time since the project ended. Documentation may be spotty; it could lack a theory of change, baseline data, and information on context and other external factors that may have influenced implementation.

What’s an evaluator to do? Our recent Health Policy and Planning article provides an overview of the WHO Guidance by outlining key contextual and methodological challenges in conducting post-project evaluations and illustrative solutions for responding to them. The Guideline is full of case studies and field-tested insights from those who have undertaken such evaluations, addressing a technical gap in this area. Those who engage with post-project evaluations need to anticipate such challenges from the beginning, and be ready, equipped, and willing to navigate them.  The goal: evaluators who feel ready and willing to conduct the most rigorous evaluation possible given available resources and project data and documentation.

Why are there so few post-project evaluations being done on promising ASRH and other projects?  We believe that the notable lack of post-project evaluations in the field is partly structural; funding agencies that support health and development programming do not typically request this type of evaluation given their project funding cycles. Even when such evaluations have been carried out, there is a gap in their accessibility and thus the distillation of evaluation experiences and strategies that can be used elsewhere. Beyond structural reasons, there also appears to be a reluctance to conduct post-project evaluation because such evaluations often do not lend themselves to the most rigorous experimental design. As such, many methodological purists and funding agencies believe it is not worth the investment. Post-project evaluation thus represents a facet of the debate around what counts as credible evidence.

Conclusion

We believe it is time to revisit post-project evaluation as a valuable and worthwhile evaluation option. The Review conducted to inform the WHO Guidance indicates that it is possible, can be rigorous, and is useful when more traditional evaluations have not been planned or carried out. Post-project evaluation should be done more frequently.  The Guidance proposes a way forward:

  • Create spaces and funding for such evaluations. Researchers and evaluators, funding agencies, and project implementers should consider and act on the utility of post-project evaluations
  • Create demand for post-project evaluations. In the absence of planned evaluation, funding agencies and governments should request post-project evaluations when a particular intervention or approach shows promise but lacks sufficient documentation
  • Build and facilitate access to post-project evaluation reports and advice on potential solutions when challenges are encountered. Most evaluation reporting remains in the grey literature; posting evaluation reports on existing government/organisational websites and evaluation clearinghouses will greatly aid efforts to compile experiences and lessons learned.

Q&A with engagement expert Emma Sparrow Part 2: Working creatively with children and young people during the COVID pandemic

Continuing from Part 1 of our Q&A last month, here’s Part 2 of our Q&A with Emma Sparrow from &Us at The Royal College of Paediatrics and Child Health.

This interview focuses on working with young people in a tricky year when it comes to participation. We asked Emma how RCPCH &Us have managed to carry on with engagement activities since Covid…

Adapting and engaging in a pandemic

Emma: We had to look at all of our projects and decide which ones are appropriate to carry on, because we had some that were about very sensitive topics that in-person would have been challenging, and would have needed a lot of support and aftercare – for example complex respiratory illnesses. We looked at those and thought, you know, what, there’s a pandemic going on, which includes respiratory illness, now’s not the time to be phoning people up or talking to them and saying, ‘what do you think about this?’ and ‘what you think about that?’ First we did a wellbeing assessment on our workstreams and agreed which ones we were going to park for a bit, based on a welfare context. Then we spoke about what the missing gap in provision might be, because everybody is going to suddenly do everything the same and we don’t want to duplicate. We actually didn’t go as quickly as some of the other organisations to put out loads of new children and young people-focused information about COVID. What we did was pull together existing information on COVID and put it into a place that was easy and clear for families, parents and children and young people to see. 

We wanted to give children and young people a meaningful role and we had to be creative 

One of the things that we wanted to do was give children and young people a meaningful role. We asked: what are the gaps? Something that came up from paediatricians was that they were really worried that children and young people wouldn’t be going to their regular appointments anymore, so could we create a child health diaryfor them? So we did, and that’s still getting downloaded now, which is really cool. It’s something a bit more creative for them to write down their questions or things that have happened that are good. A doctor came to us and said ‘we want to thank our children and young people for taking part in the covid effort and not coming in and not playing outside, so can you create an E-card?’ So we created e-cards for thank you and birthdays, and last month 5,000 of those were viewed.


We picked up on children’s and young people’s concerns

As time went on we worked with lots of other groups, virtually. Lots of Teams, Zooms, and all that kind of stuff, to find out: what’s happened for you with health during COVID? What are your appointments like and what are you missing? What’s the information like? We picked up concerns from children and young people about the fact that COVID information wasn’t targeted at them. It was for adults. It also wasn’t giving a positive message about children and young people, so they were seen as the problem rather than part of the solution. There were also significant gaps forming around mental health support. That led us into a couple of new projects focused on COVID, but specifically from children and young people’s points of view. One was about mental health in a crisis, where we wanted to children and young people to tell us where they’re getting their mental health support and where are the gaps. Another one is working with young people to try and get a press conference for young people, because they’re not allowed to ask questions at the government press conferences, you have to be over 18 – excluding a whole group from having their questions heard or having a role. So we’ve been working with other charities to call for a press conference to answer questions from children and young people.

We got young people involved in reviewing evidence on patient experience of COVID

Finally, we realised that there were thousands of studies being done on COVID. The RCPCH had clinicians coming together to review which studies were being published on children and COVID, which got me thinking that actually there was also thousands of studies being published of what young people had said. Lots of charities were asking their children and young people about the impact of the pandemic, and then publishing the results. And we just wanted to give young people a chance to also do what the adults are doing: so if doctors can review scientific journals about COVID, young people can review a patient experience of COVID. We pulled together a group of a small group of young people and over 12 weeks, invited them to look at about 20 different published studies of around 60,000 children and young people’s voices, say, from cancer patients, mental health experiences of young people, children and young people or young carers, across the UK.

And they did what we do in our world – they conducted some thematic analysis, they explored the key trends, they developed them, they then created eight different topics that came up, and they slotted in the data, with a ‘for’ and ‘against’ for each topic. Topics included things like mental health and family dynamics, employment, education. They wanted to make it make a difference to the NHS, and the NHS at the moment are writing recovery plans on how to how to restart the NHS. So they’ve boiled all of that work down and they volunteered over 100 hours doing this project over about three and a half months. They’ve turned the three priorities they have developed for the NHS into posters. The posters include the priority, the problem, the solution, the impact, a quote and some stats. Since launching, the recovery plan priorities have had about 28,000 Twitter impressions. You can read more about the COVID Book Club findings online. 

The work has elevated the voice of children and young people – and made people understand they have a lot to say

Emma: We also hosted a debate with doctors about whether paediatricians should be thinking holistically or medically during COVID, because for children and young people, it’s about their mental health as well. That project just feels so different from what we’ve done before. We had to really think through safeguarding and wellbeing, so we didn’t overwhelm the young people who led it. This project very much felt like we were actually paralleling something that was going on in the academic part of the college, and doing the exact same thing, but for children and young people, which felt very different. It has elevated children and young people’s ability, both in the college and in the sector. And it’s really made people understand that they have got a lot to say, and they understand what’s going on, and have a lot to offer. 

So on the whole, we’ve managed to find a way or find a tool or find an approach that makes it fun and entertaining and interesting and focused on them rather than the topic sometimes.

The good thing about having to change our work is that we’ve been more connected to RCPCH wider internal projects. The benefit of voice has been seen in a different way. And for us, we had to take that opportunity and run with it – we’ve had 200 new children and young people involved during the COVID pandemic, who have between them completed over 330 hours of volunteering.

Voices are being heard and the professionals are engaging more

Emma: We give advice to people that are starting out on a project or want to talk about PPI [patient & public involvement] and I’ve had so many more requests over the last three months for people that want that advice. And I think it’s because children and young people’s voice is now seen differently. They’re really seen as being integral. There’s so much further we could go, there’s a million other things we could be doing that are even more innovative and creative, and increasing their reach, but you’ve got to start somewhere.

Barriers to participation – too much time online but also digital exclusion

Emma: There’s different barriers and challenges according to which audience you’re coming from. For children and young people, one of the challenges that they’ve said to us is that it’s really overwhelming that everything is online. We’ve really got to understand that because whilst we think we’re doing something fun and exciting, and it’s online for an hour, they’ve already had school online, for some of them health appointments online, mental health appointments, and counseling online. They’ve had zoom calls with friends and family, they’ve tried to keep fit online. And then we’re coming at them with another online thing. Another challenge for them might be: maybe I haven’t got somewhere confidential and private to do online stuff where people aren’t listening in. Or maybe I haven’t got a good device. So we’ve really looked at the challenge and been as inclusive as possible. You can join our online sessions on phone, you can do it on WhatsApp, you can join via video, you can have no video. You can use the chat, or you don’t have to use the chat, you can do it by email if that’s better – it’s all your choice. For us it’s a challenge because we’re having to run four or five different tech options for a one-hour session. But it’s about understanding that not all children and young people want to be on video, not all children and young people have got a device that lets them Zoom. Maybe all they’ve got is a landline, which means they can phone in. 

The challenge for participation and engagement is don’t get complacent and think that your games and activities can all work with everyone seeing everything, because they can’t. It’s about inclusion. And that comes from children and young people saying: I might be sharing my laptop with five other people in my house, so I can’t use Teams at the same time, but I will phone in because I’ve got a mobile. We’ve had to really think it through. Another challenge is always remembering whatever you’re talking to children and young people about might be overheard. So don’t put them in positions that makes them disclose stuff that actually might not work well in their family environment. We’ve worked hard to create safe spaces, and to work with each group that we’re talking to, to make sure we understand what their space is like at that moment. Because you can’t start a conversation about money and poverty, when their parents are listening and they might feel that they’re being judged or that the young person feels like they’re judging their parents or living environment. 

How can we make it fun? How can we make it inclusive?

Another challenge has been how we can make it feel fun. If you’re using devices for presentations, or for school, we don’t want to be like school on your computer. In the back of our heads we’re always thinking let’s not overwhelm our children and young people, they don’t have to come to the project if stuff’s going on. So we’ve really been conscious about trying to understand what people might be going through. And then to think about things like don’t drink or eat when you’re on camera, because not everyone has got enough food in their house. You would do that in the meeting room, but if we were in the meeting room, we would have given them food and drink. Whereas for us on camera, we’re being really careful about stuff like that. So I think that there’s some challenges. The one that we’re looking at now is where we would normally do community outreach to reach people who aren’t connected to any projects. That will be a challenge and we need to think about how best to reach out to that cohort. But no challenge means that it’s the end and we’re not there yet! It just means that I need to think harder about how I’m going to get past it. 

I knew the COVID studies review would give young people a platform that they’ve never had before. But how can you possibly do that safely? If I was in the room, I’m able to see their visual cues, I’m able to unpack things over lunch, I’m able to stop the session and do something entirely different. I spoke to a friend who’s a youth worker and she said: ask the young people, they’ll tell you what works for them, so we did, and they knew all the answers and helped shape the project throughout. In the end they decided that we couldn’t do all of the studies. We found 33 but they said that they could only manage a certain number but that’s cool. At every stage I just kept checking in with them. They will tell us what works for them. It’s co production even in that sense.

What tools can we use for remote working with children and young people?

The first thing I would have to say for anyone about to do is go and talk to your information governance manager. Because whatever you think might be able to be used might not be able to be used for lots of different reasons. One thing we used is Trello , because the young people said for the COVID studies review they wanted somewhere where they could collaborate on documents, but we can’t use Google Docs because of a GDPR issue. I’ve never used anything like that before with young people. It’s so good. They could ask questions and comment on each other’s documents. But they could also see really clearly what was happening at what stage and what they could add to if they had a bit more time. I’ve been trying to find a voting app online, because that is key to so many of our projects, to be able to anonymously prioritise five or six different things. And Menti allows you to do that. You don’t have to put any personal data in, you just get given a code. And then they’ve got lots of different voting tools that you can use. Having a virtual whiteboard is really important as well, like JamBoard. But going back to inclusivity, if we’re using JamBoard, and I’ve got two people that phoned in, I will take a screen grab of it and then WhatsApp it to them so they can see it building. And it’s keeping that in mind as well, to make sure that you’re not inadvertently excluding someone because they haven’t got the same software in front of them.

Overall, I think we keep adapting, learning and changing to the meet the needs of children and young people engaging with us through the pandemic, as we learn new digital tools or approaches and learn from the group. It’s been an opportunity to really relearn everything you have always done and to reflect, update and adapt which has been hard at times but so rewarding when you see the outputs and outcomes. 

Attendees at the participatory dissemination event for This Sickle Cell Life with DEPTH at LSHTM and RCPCH’s &Us (Photo: Anne Koerber)

Contacts

To find out more about the RCPCH &Us programme or to access their free resources and support go to www.rcpch.ac.uk/and_us or contact and_us@rcpch.ac.uk, and follow them on twitter @RCPCH_and_Us.

You can read about the RCPCH & Us collaboration with LSHTM on ‘This Sickle Cell Life’ here.

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Decolonial practice for library collections, part 2

The Library uses the Barnard Classification Scheme to organise print resources into subject-related categories.  Cyril Barnard was the School’s first professional librarian, and he wrote his A classification for medical and veterinary libraries in 1936, amended in 1955.  There was an urgent need to update the scheme so that it met collections-specific requirements, reflected teaching and research priorities of the School, and banished the colonial thinking and knowledge organisation of the 1950s.  Revisions included:

  • Subject headings and descriptions reviewed and removed/updated as necessary, new subject headings added (classes and tables)
  • Decolonised language and descriptions used (esp. removal of racist and sexist terms)
  • Updated content of classes so relevant for C21st incl. scientific and medical advances, political and economic developments, sociocultural changes, demographics, technological changes, etc.
  • Restored relevance to contemporary research (led by LSHTM research and teaching)
  • Hierarchical structures/indentations removed where indicated colonial bias/superiority
  • Latinised nomenclature still used, but knowledge of scientific classification no longer assumed (e.g. bacteriology, Class J; virology, Class K)
  • Table 2 (geographic subdivision): reflects transition to independent states, esp. decolonisation of Africa, Americas, Asia, Oceania.  Note: not only British Empire, but also French Colonial Empire, Dutch, Portuguese, Belgium, Italy, Japan. Removal of indentations which signified power structures.  Less weighting to USA and UK locations.

The first draft of the 3rd edition of Barnard’s scheme was completed in August 2020. Decolonising catalogue records and re-classifying the print book collection began in April 2021 and to date 1.7k book classifications have been updated. In May, work began on re-classifying the pamphlet collection. New print book acquisitions are being catalogued in line with the 3rd edition. 

As a gatekeeper in the transmission of information, the Library can actively contribute to the decolonisation of practices and processes linked to colonialism:

  • Targeted decolonisation of catalogue records​
  • Increased discoverability and accessibility of subjects and resources in collections
  • Greater transparency and inclusivity in cataloguing and classification processes​
  • Open acknowledgement of Western bias in science and knowledge classifications; need to contextualise resources​
  • Empowered readers who reflect on resources through a critical decolonial lens
  • Provide data (collections content, reading list citations) and support in School’s decolonising activities​
  • Broadening of collection development

Decolonial practice for library collections, part 1

University library collections support the teaching and research demands placed by the organisation in which they are embedded.  Not only are resources in collections dominated by thought and knowledge creation of the global north, but several library practices contribute to this colonial bias. The nature of library collections has traditionally been seen as the control and classification of resources, leading to a Western commodification of knowledge. Cataloguing conventions often convey a bias to the global north.  In addition to the unfamiliar language of library catalogues, readers face colonial bias when searching for resources. New technologies enable unprecedented access to collections but tend to inherit the search hierarchies and language bias of the classification schemes which provide the browsing structures for subject-based information gateways.

In 2019 the Library carried out a review of its collections to gauge the extent of colonial bias.  Developments in Collections since 2019 meant significantly more print and online content was available.  Another review was carried out in March 2021.  Data was collected from Alma (the Library’s LSP – Library Services Platform) incl. publication/distribution information (MARC 260 field) and classification details, e-content package and publisher/supplier information, and internal data sources.  Records analysed: 19k print books, 10.6k pamphlets, 700 eBooks, 6k eJournals, 900 print journals.

  • All physical and online collections (books, journals, pamphlets) heavily dominated by material published in the global north
  • Significant percentage of print resources published before the ‘end of Empire’.  Can surmise that the legacy of colonialism would be found throughout print collections.
  • Europe and North America had done majority of publishing about their own continent and about other continents
  • Africa and Asia had mainly been written about
  • Minimal holdings on (or by) Eurasia, Oceania and South America
  • Recent acquisitions (print and online) still mainly published in the global north, with this dominance often increasing

The results detailed above led to questions being asked about reading list content.  A review was carried out in August 2020, and another in February 2021.  Analysis was limited by the underlying metadata available in Alma, but 11.6k citations were looked at from 193 active reading lists.  Books with the most citations were published in the UK and the USA, and journals with the most citations were published in the USA, the UK, and the Netherlands.  59% citations were for journal content, with 22% of them published by Elsevier.  BMJ Publishing, Elsevier, Oxford University Press, and Wiley had >500 citations each.  10% of all citations were for The Lancet (Elsevier) and BMJ (BMJ Publishing).  As with print books and pamphlets, citations appeared to show Africa and Asia being published about, and only a small percentage of content focusing on Eurasia, Oceania and South America. 

To conclude, discovering that older resources in the collections were dominated by publishers based in the global north was not surprising.  However, finding that recent print acquisitions and electronic resources not only continued this Western control over the production of knowledge and access to it, but had actually increased this dominance, was concerning and thought-provoking. 

How To Be an Ally This LGBTQ+ Pride Month

The progress flag with the LSHTM logo. The progress flag is the LGBTQ+ rainbow flag with black and brown stripes and trans flag stripes.

LGBTQ+ Pride month celebrates all the advances in queer rights in recent times, it remembers the fight for those rights, and prompts us to reflect on how much there is still to do. LGBTQ+ people remain one of the most marginalised groups worldwide. Even in London, with Soho on our doorstep and rainbow flags on our rooves, the queer experience leaves a lot to be desired.

Pride month is also a time to acknowledge that resourceful and creative as we are, LGBTQ+ people could not have achieved the advances we have made to date without our allies. An ally is a person who chooses to align with efforts to improve the circumstances for individuals from a marginalised or disadvantaged group. Being an ally is not just a humanitarian position but also a moral position – if you’re not part of the solution…

The biggest barrier to effective allyship isn’t ignorance or even apathy. Often, it’s the lack of confidence to step into the role, a lack of awareness of what that entails and how one enacts ‘allyship’ effectively. How can you help others live authentically when their experience is so different to yours?  How can you roll your sleeves up, put your privilege to one side, and get stuck in making the world a better place for queers?

Thankfully, being an ally is rather straightforward. Not always easy, but straightforward. LinkedIn Learning’s Dr Daisy Lovelace has managed to distil the key components of effective allyship into an acronym that, handily, spells ‘ally’.

Act. Speak up and call out anti-LGBTQ+ language, actions and cultures. A bystander who takes a neutral or non-objecting stance isn’t an ally. An ally speaks up for the rights of LGBTQ+ people even – especially – when there are no LGBTQ+ people around to speak up for themselves. It’s not always big actions that are needed. Sometimes it’s a simple as reminding your team to use gender neutral language or use queer-inclusive images. Sometimes big actions are needed and that’s when we need allies the most. Allies are our bridges from the margins to the mainstream and we need you to act with us consistently and reliably if our progress towards equality is to be maintained.

Learn. The queer experience is tough but it’s also amazing. Standing on the outside looking in on a world you’ll never belong to is a simultaneously painful and liberating perspective. The unique creative viewpoint that comes from such painful liberation is, truly, glorious and cuts to the core of why queer people love who we are. As an ally it’s important to learn about the LGBTQ+ experience, to learn what it means to grow up queer and how that impacts a person now. None of us have grown up unscathed and it’s important to hear our experiences and learn from them if society is to evolve beyond tolerance to acceptance and, hopefully, inclusion.

Listen. With all due respect, LGBTQ+ people don’t need the “straight perspective” on the queer experience. There’s nothing worse than the mainstream telling the margins how to live or what our needs are. At best it betrays a lack of self-awareness but at worst it smacks of the heteronormative arrogance that assumes all queer people want to be like cis-gendered straight people. We don’t – but don’t take my word for it. Listen instead to all the LGBTQ+ people in your own life. Listen and really try to hear who we are, what we’ve been through, and what living authentically means for us.

Yield your privilege. Privilege gives you choice whether to be neutral on an issue or not, it allows you to navigate the world without needing to give a thought to the marginalised groups you’re not a part of. It’s likely we all have some privilege or other and some people may live a life of near-total privilege. The important thing isn’t whether or not you have privilege: it’s what you do with it that counts. Yielding your privilege means you choose not to be neutral and to stand alongside those without the privilege in the first place. It means using your status to help marginalised people be heard and achieve equitable status in society without having to compromise who they are or how they express themselves. Yielding your privilege to LGBTQ+ people means championing queer-inclusive spaces and practices in our organisation while rejecting non-inclusive practices even when you’d receive a benefit from them. It is an act of true allyship, the signature move of a true ally.

Being an ally isn’t always, or even often, easy but it is needed and always appreciated. Pride month is an opportunity for the LGBTQ+ community to express gratitude to our allies – sincerely, thank you – but also to reaffirm how much we need you and how you can best help us. It is a mistake to think the work of LGBTQ+ inclusion is complete even locally, there is still a massive gap to close. This Pride month we acknowledge that gap and ask you to be an ally, to stand with us and help make the world a safer place, an easier place, for lesbian, gay, bisexual, trans, non-binary and gender non-conforming people.

By Aiden Gillan-Bronze
Digital Education Manager
Disability & Eye Health Group, LSHTM

Is criminalization the answer for ending a harmful practice in Nepal?

By Sara E. Baumann (University of Pittsburgh Graduate School of Public Health)

Images of women and girls sleeping in small sheds in far-flung Himalayan villages have made the in recent years. They are following a centuries old practice called chhaupadi, or menstrual seclusion, in which women and girls are isolated due to a belief that they are impure during menstruation. Often, images of women crouched in dilapidated huts are paired with headlines like, “Where a taboo is leading to the death of young girls” and “In Nepal, tradition is killing women.” But in 2017, the headlines began to shift, with a new focus on the recent criminalization of chhaupadi. Headlines began to pose the question, “Nepal outlaws menstruation huts, but what will take their place?” As a researcher working to generate evidence to inform polices and interventions aiming to improve the lives of Nepali women and girls, I found myself wondering: Are communities and police aware of the new criminal code? If so, what do community members and police think about it? And is criminalization the answer for addressing this deeply-rooted social and cultural practice?

Our new article published in Health Policy and Planning explores these questions through an investigation that took our team deep into the high Himalayan mountains in far-west Nepal. We hiked hours to remote villages where the practice is widespread to gather insights from a range of community members, including fathers, teachers, faith leaders, elders, mothers, adolescent girls, out of school girls, traditional healers, health care providers, and police. Many of the discussions that unfolded surprised us.

Remoteness can lead to challenges in sharing accurate information about the latest health policies. Kalikot district.

While limited knowledge of the criminal code among community members living in remote parts of Nepal was expected – given the remote landscape and limited number of awareness-raising interventions – discovering extremely low levels of awareness among working professionals directly involved in menstrual health and law enforcement was surprising. A lack of awareness regarding the criminal code among many health workers and police was concerning.

Interestingly, after informing community members of the new criminal code, we found that reactions to chhaupadi criminalization were generally positive. In fact, one third of participants expressed that they plan to change their behaviors now that they have learned that the practice is publishable with fines and/or jail time. The study also highlights an interesting perspective from those who have traditionally upheld the practice, such as grandmothers, mothers, traditional healers, and religious leaders. Many of them expressed that the law is likely to change behaviors if community members are made aware of it, and if objective and timely implementation occur.

So, is criminalization the answer? Our findings suggest that a range of community members are supportive of the legislative changes and are hopeful that these policy actions will bring about change. According to the respondents in this study of various backgrounds, criminalizing the practice is a strong start to build upon with awareness and behavior change activities.

Conclusion

Results from this study indicate, from both the perspectives of community members and law enforcement, that criminalization is generally viewed as a positive action for initiating chhaupadi behavior change. However, accurate information about the legislation is extremely low, and thus initiatives are urgently needed to ensure communities and law enforcement are informed of the criminalization and associated penalties. Additionally, even after criminalization, behavior change is anticipated to be gradual and require long-term behavior change interventions that target social pressures associated with upholding the tradition, raising awareness, ensuring mutual cooperation, organizing trainings, involving women and non-governmental organizations, as well as engaging the media. Overall, lessons learned from this study are informative for developing interventions that build upon the momentum of the recent chhaupadi criminalization.  Specially, addressing harmful chhaupadi behaviors will require systematic and timely communication channels for sharing the latest information about new codes, a strategy for equitable and timely enforcement of the criminal code at the district and community levels, long-term awareness-raising interventions, and incorporating gatekeepers of the tradition into behavior change interventions. Read our HPP paper for more information about our recommendations, which aim to build upon the momentum initiated by the chhaupadi criminal code.


Access the paper: Is criminalization the answer? Perspectives of community members and police on menstrual seclusion policy in Far-West Nepal

Image credits: Sara E. Baumann

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Antibiotic Resistance: Lessons from Behaviour Change Interventions in LMICs

By Carla Cuevas (University College London), Neha Batura (University College London), Luh Putu Lila Wulandari (University of New South Wales and Udayana University), Mishal Khan (London School of Hygiene & Tropical Medicine and Aga Khan University) and Virginia Wiseman (University of New South Wales and London School of Hygiene & Tropical Medicine)

Since their first use, antibiotics have played a key role in preventing and treating bacterial infections. They have saved patients’ lives, and extended life spans, worldwide. However, the overuse and misuse of antibiotics has led to the evolution of bacteria strains that are resistant to antibiotics. Thus, several infections, for example, pneumonia, tuberculosis, blood, and foodborne diseases have become harder to treat as antibiotics are becoming less effective. The prevalence and spread of antibiotic resistance (ABR) is made worse when antibiotics can be bought for animal or human consumption without a prescription . This, in combination with over-prescription of antibiotics in the absence of standard treatment guidelines has exacerbated ABR. If not contained, the spread of ABR will increase the burden on patients who suffer from prolonged illnesses as well as on their families and on global health systems.

A wide variety of interventions to improve the use of antibiotics have been implemented, largely in high-income settings, with mixed results. As an interdisciplary team, whose research experience is grounded in health systems in low- and middle-income countries (LMICs), we noted a gap in the evidence for these settings. This inspired us to explore how the behaviour of health care providers and patients could be changed  in order to improve the use of antibiotics and counter the spread of antibiotic resistance in an article published in Health Policy and Planning.

There are a few points that are important to highlight about our research that could give us some new information about ways of improving and controlling the spread of ABR:

  1. A combination of behaviour change strategies is likely to be more effective than a single strategy

We found that interventions incorporating educational activities, training programmes, supportive feedback and supervison loops, and guideline development and enforcement were more likely to positively affect provider behaviour. However, interventions consisting of multiple strategies, for example, training programmes combined with educational activities or guideline adherence were more effective than training programmes alone. This is likely because the motivation, skills, knowledge, tools and experiences delivered by educational activities can strengthen the impact of a training Thus, policies that focus on one strategy alone may be less effective in improving the use of antibiotics.

  1. Excluding providers in the private sector may hamper efforts to improve the use of antibiotics

Most interventions targeted public sector health providers, particularly doctors but only a handful of interventions targeted other health providers who are also able to prescribe or dispense antibiotics, such as nurses, community health workers, and pharmacy workers. It is important to expand efforts to include these groups, who are often the first point of careseeking contact in LMICs. This is particularly important in settings where antibiotics (and other medicines) can be bought over-the-counter without a prescription, and used without adequate information about correct dosage, and length of treatment.

  1. Patients and communities also have a key role to play in improved antibiotic use

A small number of interventions were targeted at patients and communities. Patient behaviour such as using antibtioics for long periods of time, not adhering to recommended treatment and dosing schedules, stock piling left over antibiotics at home for later use, and using antibiotics to treat uncomplicated viral infections can lead to an increase in ABR. Designing interventions to deliver information about the appropriate use of antibiotics for different illnesses, and complementary social marketing campaigns could improve the use of antibiotics amongst this very important population.

  1. Low- and middle-income countries have an important role to play in global strategies to combat ABR but there is a paucity of information in these settings

ABR is growing at an accelerating pace in LMICs, and several countries have been tasked to develop and implement nationwide strategies to curb ABR. Our research found that there is limited evidence on how antibiotics are used, patterns of ABR amongst the population, and how these change over time in LMICs. Without such evidence, it is challenging to develop and implement effective regulatory, economic or legislative policies to improve antibiotic use.

5. Urgently need to understand why interventions work (or do not) and their cost-effectiveness

Our research found that most of the intervention evaluations did not unpack why an intervention strategy worked (or did not). Further, only a handful of evaluations explored value for money or affordability dimensions of interventions. The lack of such evidence could pose a challenge to decision makers  and thus, limit to uptake and scale-up of behaviour change strategies to improve the use of antibtioics.

Conclusion

Tackling ABR is a complex process involving us all – as individuals, health professionals and members of society. Our review found that antibiotic use by health care providers could be most effectively improved by using multiple behaviour change strategies in combination, such as on education, restriction and training. It also highlighted  lay people and private healthcare providers, who are major users of antibtiotics are not as strongly focussed on as public healthcare providers, in LMICs. Looking ahead, decision-makers investing in controlling ABR would benefit from evidence on the groups that are currently poorly studied, and on which interventions are cost-effective and affordable.


Access the Paper

Improving antibiotic use through behaviour change: a systematic review of interventions evaluated in low- and middle-income countries
Carla Cuevas, Neha Batura, Luh Putu Lila Wulandari, Mishal Khan, Virginia Wiseman

Eye Health in the Commonwealth: Publication of Progress Report 2018-2020

This month marks the publication of the first two-yearly report on action of the Commonwealth Heads of Government Meeting (CHOGM), a meeting of the 54 countries of the international Commonwealth, in relation to eye health.

The report, covering the years 2018-2020 follows from a meeting in London in 2018 which included a committment towards achieving access to quality eye care for all, including eliminating blinding trachoma. The document presents progress towards these goals, and includes recommendations for the future. Its key recommendation is that the Commonwealth make a commitment to school eye health to unlock the potential of every child.

The report was authored by ICEH Associate Professor Dr Fatima Kyari. Fatima is an ophthalmologist and Honorary Consultant at University of Abuja Teaching Hospital.

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Henry Vandyke Carter (1831-1897): LSHTM Rare Books blog series No. 1

HENRY VANDYKE CARTER (1831-1897) : author of On Leprosy and Elephantiasis,  and the artist for Gray’s Anatomy

Gray’s Anatomy is a classic medical textbook, used by doctors, anatomists and medical artists.  Yet, despite Henry Gray’s (1826/27-1861) scholarly text running to 720 pages, it is unlikely the book would have retained its acclaimed position (it has been in print continuously since 1858), were it not for the brilliant 363 text-figures – one on every other page. Credit for the illustrations is due to the subject of this blog – Henry Vandyke Carter. However, it is not for Carter’s artistic ability that he is represented in the Special Books Collection but rather for his book On Leprosy and Elephantiasis (1874), the result of his research in Southern India.  

Figure 1: Portrait of Henry Vandyke Carter. (Wellcome Library)

Education and Career

Henry Vandyke Carter was born on 22 May 1831 in Hull, a port city in Yorkshire, England, the son of a marine artist. Although Henry Carter was a naturally gifted artist (as exemplified in Gray’s Anatomy), and doubtless could have taken that career path, to be a physician was his ambition. Being unable to afford to study medicine at university, Henry took the alternative route, taking an apprenticeship to an apothecary in Mayfair in 1848 and studying surgery at St George’s Hospital Medical School (now the Lanesborough Hotel) situated just on the other side of Hyde Park Corner.  Henry qualified to work as a general practitioner by gaining membership of the Royal College of Surgeons of England (M.R.C.S.) and an apothecary’s licence (L.S.A.) in 1852.  Henry’s goal, however, was to work in hospitals with laboratory facilities for research : in furtherance of this ambition he went to Paris to gain more experience, 1852-53.

Henry secured some financial stability when, back in England, he obtained a studentship in human and comparative anatomy at the Hunterian Museum of the Royal College of Surgeons, June 1853-June 1855.    The job was mundane but the great advantage it brought was the opportunity to work under two outstanding British scientists – Richard Owen (1804-1892), comparative anatomist and John Thomas Quekett (1815-1861), microscopist.  He was also, until July 1857, Demonstrator in Anatomy at St. George’s Hospital. Whilst carrying on with his jobs, Henry studied at University College Hospital, obtaining his M.B. (1854) and M.D. (1856) from the University of London.

As Henry was not able to find a suitable position in Britain after qualifying, he joined the Indian Medical Service in 1858 as Assistant Surgeon in the Bombay Medical Service.  India was not a destination for the faint-hearted. On the one hand there was the lure of the exotic and fortunes to be made, on the other many European lives were lost to tropical diseases they did not understand and reverberations from the Indian Mutiny (1857) were still being felt.  Undeterred, Henry Carter  purchased the necessary tropical kit, microscope, and books and left England in February and reached Bombay (now Mumbai) in March, 1858. He was 27. Initially he treated soldiers wounded in the Indian Mutiny at Fort George, an army post outside Bombay, before a transfer to the Grant Medical College for Indian students and its affiliated Jamsetjee Jeejeebhoy Hospital in Bombay in 1860.  Most of his 30-year career was spent at the College, as Principal from 1881.  He retired in July 1888 aged 57 with the honorary rank of Brigade-Surgeon. His personal life in India was marred early by a scandal resulting from an invalid marriage in 1859. He re-married in England in 1890 and had two children. Henry was appointed Honorary Physician to Queen Victoria in 1890. He died of tuberculosis on 4 May 1897 in Scarborough, Yorkshire, aged 65.

Medical Artist

Carter and Gray met when seventeen-year old student Henry Carter attended Henry Gray’s anatomy classes at St. George’s Hospital where his painterly skills had already been employed to design some wall charts. Gray engaged him to illustrate his first book, a specialised work on The Spleen (Gray, 1854), and some reviewers referred to the high-quality of the 64 woodcut figures (Richardson 2008 : 31), although Carter’s name was omitted from the acknowledgements.

Over the next three years, 1855-1858, the pair worked together on the Anatomy; Gray prepared the text while Henry drew the 363 figures, dissecting corpses to better understand and record anatomical structure. Queckett’s training in microscopy was to prove invaluable for when Henry was preparing the illustrations and, later, in the tropics. This time Henry Carter was properly accredited on the title-page of the Anatomy.  Gray died in 1861 of smallpox aged only 34.

Figure 2: Illustration of large arteries and veins in the neck; Henry Vandyke Carter (Wellcome Library)

Scientific Research

All Henry’s research took place in Bombay where many patients presented with diseases that were unknown to European doctors, like the Indian labourers who came to the Hospital with painful swellings on their feet.  Henry correctly postulated the cause was a fungus entering the men’s bare feet but he could not prove it (Carter 1861). Later, after confirmation of his theory, the disease was named Carter’s mycetoma.

Leprosy was the most noticeable medical condition seen in the population. Soon after arrival at the Jamsetjee Jeejeebhoy Hospital Henry conducted a major review of the disease (Carter 1863) and, after publication of the 1867 Bombay Presidency census, he extracted data on 8,220 Indian lepers (Carter 1871).  From 1873-75 Henry was in Europe principally to consult the Norwegian physician Gerhard Henrik Armauer Hansen (1841-1912), the scientist leading research on the cause of leprosy and care of patients by segregation and treatment. Hansen concluded leprosy was an acquired bacterial infection caused by Mycobacterium  leprae and not a hereditary disease as many believed : it is now also known as Hansen’s disease.  Henry reported Hansen’s important work in English-language medical literature thereby making it more widely available (Carter 1874a; Carter 1874c).

Shortly after Henry returned to Bombay from Europe the 1877-78 famine struck. Starving patients arrived at the Jamsetjee Jeejeebhoy Hospital suffering from an associated relapsing fever. Working in the Hospital’s Pathology Laboratory Henry identified the cause was a bacterium,  Spirillum minus, in the blood.  In 1881 Henry was invited to give a paper on relapsing fever at the 7th International Medical Congress in London attended by eminent scientists including Louis Pasteur, Robert Koch and Joseph Lister (Carter 1882).

The LSHTM copy of On Leprosy and Elephantiasis with plates

On Leprosy and Elephantiasis with plates was published in London in 1874.  The large book, 39 cm in height, was acquired on 30 May 1939, but its earlier provenance is unknown. The Library had it rebound in its present plain, black cloth binding, possibly in 1959. It has nearly 250 pages of text and 15 lithographed plates, many hand-coloured, after Henry’s original drawings.  Nine plates portray leprosy patients in India and Norway, three are microscopy studies, and three plates depict  elephantiasis. Each plate has a facing page of captions. 

Figures 3-5: Lithograph plates from On Leprosy (1874)

In leprosy and Elephantiasis, despite the title, describes leprosy only, except for a single page (p.213) on elephantiasis. Elephantiasis had been linked to leprosy, a theory Henry doubted :  “But it is not supposed that this affliction [elephantiasis] is allied to true leprosy” (Carter 1874a: 213).  Shortly afterwards Patrick Manson (1844-1922), working in China in 1877-78, discovered elephantiasis was caused by a parasitic worm, Wuchereria bancrofti, that was spread by mosquito vectors.  

Select list of Henry Vandyke Carter’s publications.

1861. On a new and striking form of fungus disease, principally affecting the foot, and prevailing endemically in many parts of India. Transactions of the Medical and Physical Society of Bombay 6 (NS) (1860) : 104-142.

1863. On the symptoms and morbid anatomy of leprosy: with remarks. Transactions of the Medical and Physical Society of Bombay 8 (NS) : 1-104.

1871. Report on the prevalence and characters of leprosy in the Bombay Presidency, India, based on the official returns of 1867. Transactions of the Medical and Physical Society of Bombay 11 (NS) : 74-248.

1874a. On Leprosy and Elephantiasis with Plates. London : Printed by George Edward Eyre & William Spottiswoode.  v, 213, xxxviii pages, xv leaves, [15] leaves of plates, [2] maps, [1] photographic plate, [1] plan, folded.

1874b. On Mycetoma, or the Fungus Disease of India. London : J. & A. Churchill.

1874c. Report on Leprosy and Leper-Asylums in Norway. With reference to India. London : G.E. Eyre & W. Spottiswoode.

1882. Spirillum Fever: synonyms : famine or relapsing fever as seen in Western India.  London : J. & A. Churchill.

References

GRAY, Henry, 1853. On the Structure and Use of the Spleen. London : John W. Parker and Son.

GRAY Henry, 1858. Anatomy, Descriptive and Surgical. … The Drawings by H.V. Carter. The Dissections jointly by the Author and Dr. Carter. London : John W. Parker and Son. 720 pages.

HAYES, Bill, 2009. The Anatomist : A True Story of Gray’s Anatomy. New York : Bellvue Literary Press.

RICHARDSON, Ruth, 2008. The Making of Mr. Gray’s Anatomy. Bodies, Books, Fortune, Fame. Oxford : University Press.

The LSHTM Rare Books blog series is an occasional posting highlighting books that are landmarks in the understanding of tropical medicine and public health.  The Rare Books Collection was initiated by Cyril Cuthbert Barnard (1894-1959), the first Librarian, from donations and purchases, assisted with grants from the Carnegie United Kingdom Trust. There are approximately 1600 historically important rare and antiquarian books in the Rare Books Collection.

Many of the LSHTM Library’s rare books were digitised as part of the UK Medical Heritage Library. This provides high-quality, copyright-free downloads of over 200,000 books and pamphlets from the 19th and early 20th century. To help preserve the rare books, please consult the digital copy in the first instance.

If the book has not been digitised or if you need to consult the physical object, please request access on the Library’s Discover search service. Use the search function to find the book you would like to view. Click the title to view more information and then click ‘Request’. You can also email library@lshtm.ac.uk with details of the item you wish to view. A librarian will get in touch to arrange a time for you to view the item.

Researchers wishing to view the physical rare books must abide by the Guidelines for using the archives and complete and sign a registration form which signifies their agreement to abide by the archive rules. More information is available on the Visiting the Archives webpage.

Your chance to have your say!

We’re seeking your feedback on how we’ve been doing during this academic year. If you’re a student at the London School of Hygiene and Tropical Medicine (LSHTM) should have received an email from the Library asking you three questions:

  1. Overall how satisfied are you with the LSHTM Library & Archives Service?
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  3. How satisfied are you with LSHTM Library support and training?

All you need to do is open the email and click on the link that best describes your level of satisfaction for each question.

You’ll then be given the option to leave more detailed feedback if you want to.

The feedback we get from students and staff guides our decision making and helps improve the Library & Archives Service for future users. Some changes we’ve made in recent years as a result of user feedback are:

  1. An improved Inter-Library Loan request form
  2. Rescheduling our literature searching sessions later in the academic year
  3. Installation of a water cooler in Library
  4. Changes to food and drink rules in the Library
  5. Introduced online registration to Senate House Library electronic resources

If you’re able to visit our Library take a look at our ‘You Said We Did’ display above the water cooler, or have a look at our feedback responses page on the Student Portal/Staff Intranet. No matter what the time of year, we are always interested in hearing from you and have multiple ways for you to get in touch:

Thank you for your feedback!