Implementing “from here to there”: A case study of conceptual and practical challenges in implementation science

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.https://doi.org/10.1016/j.socscimed.2022.114959301pubpu

Improving human and environmental health in urban informal settlements: the Revitalising Informal Settlements and their Environments (RISE) programme

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420https://doi.org/10.1016/S2542-5196(18)30114-12pubpubSuppl

Implementing baseline ecological and human health field assessments in the Revitalizing Informal Settlements and their Environments (RISE) programme in Makassar, Indonesia: an interdisciplinary study

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420Background The Revitalizing Informal Settlements and their Environments (RISE) programme aims to assess the health, wellbeing, and ecological impacts of a water-sensitive-cities approach to improving urban informal settlements. Incorporating water-cycle management and green technology sanitation strategies, we aim to reduce flood risk and improve sanitation and waste water treatment leading to cleaner and healthier environments. Here we present the initial design pre-intervention for evaluation in the first 12 settlements in Makassar, Indonesia. Methods Initial environmental, and wellbeing and human health assessments were implemented starting in October, 2018, in 12 settlements in Makassar, Indonesia. Ecological assessments include measuring of temperature and humidity via iButtons installed in select homes, recording of bio-acoustic to measure biodiversity within settlement boundaries, and trapping disease vectors quarterly. Implemented evaluation of environmental contamination includes sampling water and soil sources for total coliforms as well as collecting soil via bootsocks by walking predefined transects. Human assessment includes an annual baseline survey of all settlement households, assessing self-reported symptoms, health-care system utilisation, and subjective wellbeing. Additionally, children younger than 5 years are surveyed quarterly for caregiver reported symptoms of diarrhoea and febrile illness, blood samples and anthropometry are being collected annually, and faeces samples are requested quarterly. Findings Ecological assessments have provided more than a million temperature data points. 21 000 mosquitos have been captured and identified. A total of 114 water samples, 84 bootsocks, and 91 soil samples have been collected, with sampling prior to and during the wet season. We have identified over 600 households within the 12 settlements. Health assessments of children under the age of 5 years have revealed 282 children with collection of 234 faeces samples and 188 blood samples. Interpretation We have successfully implemented baseline ecological and human health and wellbeing assessment tools in all 12 settlements, which will allow for the evaluation of water-sensitive-cities approach in RISE programme.https://doi.org/10.1016/S2542-5196(19)30151-23Suppl

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

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420Introduction 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.pubpu

A planetary health model for reducing exposure to faecal contamination in urban informal settlements: Baseline findings from Makassar, Indonesia

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420Background 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.https://doi.org/10.1016/j.envint.2021.106679155pubpu

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

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

The space of dwelling: an investigation into the potential for spatial flexibility to improve volume housing in Australia

This PhD explores architectural contributions in the design and delivery of volume housing, which provides the most affordable housing option in the Australian market. The study develops different design strategies for incorporating spatial flexibility in four housing projects: The Dividable House, The Adaptable House, The Adaptable Apartment and The Flexible Townhouse, stemming from the Sustainable Affordable Home initiative (SAHI) and Designing Affordable Sustainable Housing (DASH). These projects, commissioned by Victorian State Government authorities, aim to provide design improvements that can be adopted at negligible increase in cost to the dwelling. In addition to the housing design projects, the design research has been developed through case-study analysis and the development of hypothetical occupancy scenarios. The design projects, developed between 2006 and 2011 as demonstration projects aimed at volume housing providers in Melbourne, were conceptualised to offer flexible spatial designs in response to the social, economic and environmental issues that current models of volume housing struggle to address. The Adaptable House, stemming from the SAHI project, was built in 2010 by the volume builder Burbank. These projects, as well as the design research that accompanied them, were developed through the collaborative efforts of research teams. The SAHI projects were completed in collaboration with Professor Shane Murray and Graham Crist. The DASH projects were conducted under the auspices of the Monash Architecture Studio in collaboration with Professor Shane Murray, Lee-Anne Khor, Ross Brewin, Tom Morgan, Barend Meyer, Professor Nigel Bertram, Louise Wright and Studio m-b

The space of dwelling: an investigation into the potential for spatial flexibility to improve volume housing in Australia

This PhD explores architectural contributions in the design and delivery of volume housing, which provides the most affordable housing option in the Australian market. The study develops different design strategies for incorporating spatial flexibility in four housing projects: The Dividable House, The Adaptable House, The Adaptable Apartment and The Flexible Townhouse, stemming from the Sustainable Affordable Home initiative (SAHI) and Designing Affordable Sustainable Housing (DASH). These projects, commissioned by Victorian State Government authorities, aim to provide design improvements that can be adopted at negligible increase in cost to the dwelling. In addition to the housing design projects, the design research has been developed through case-study analysis and the development of hypothetical occupancy scenarios. The design projects, developed between 2006 and 2011 as demonstration projects aimed at volume housing providers in Melbourne, were conceptualised to offer flexible spatial designs in response to the social, economic and environmental issues that current models of volume housing struggle to address. The Adaptable House, stemming from the SAHI project, was built in 2010 by the volume builder Burbank. These projects, as well as the design research that accompanied them, were developed through the collaborative efforts of research teams. The SAHI projects were completed in collaboration with Professor Shane Murray and Graham Crist. The DASH projects were conducted under the auspices of the Monash Architecture Studio in collaboration with Professor Shane Murray, Lee-Anne Khor, Ross Brewin, Tom Morgan, Barend Meyer, Professor Nigel Bertram, Louise Wright and Studio m-b

Informal Land Rights and Infrastructure Retrofit: A Typology of Land Rights in Informal Settlements

Informal settlements represent a challenging operational context for local government service providers due to precarious contextual conditions. Location choice and land procurement for public infrastructure raise the complicated question: who has the right to occupy, control, and use a piece of land in informal settlements? There is currently a dearth of intelligence on how to identify well-located land for public infrastructure, spatially and with careful consideration for safeguarding the claimed rights and preventing conflicts. Drawing on a case study of green infrastructure retrofit in seven informal settlements in Makassar, Indonesia, we classify the informal settlers’ land rights into four types: ownership, use, control, and management. This exploratory study uses a typological approach to investigate the spatial dimension of land rights in informal settlements. We introduce non-registrable land interests and the partial, dynamic, and informal land use rights that impact the land procurement for infrastructure retrofit. We also create a simple spatial matrix describing the control/power, responsibilities and land interests of different stakeholders involved in the location decision making for public infrastructure. We argue that without sufficient understanding of non-formal land rights, land procurement proposals for the public infrastructure upgrades can be frustrated by the individual or group claims on the land, making the service provision impossible in informal settlements

Informal Land Rights and Infrastructure Retrofit: A Typology of Land Rights in Informal Settlements

Informal settlements represent a challenging operational context for local government service providers due to precarious contextual conditions. Location choice and land procurement for public infrastructure raise the complicated question: who has the right to occupy, control, and use a piece of land in informal settlements? There is currently a dearth of intelligence on how to identify well-located land for public infrastructure, spatially and with careful consideration for safeguarding the claimed rights and preventing conflicts. Drawing on a case study of green infrastructure retrofit in seven informal settlements in Makassar, Indonesia, we classify the informal settlers’ land rights into four types: ownership, use, control, and management. This exploratory study uses a typological approach to investigate the spatial dimension of land rights in informal settlements. We introduce non-registrable land interests and the partial, dynamic, and informal land use rights that impact the land procurement for infrastructure retrofit. We also create a simple spatial matrix describing the control/power, responsibilities and land interests of different stakeholders involved in the location decision making for public infrastructure. We argue that without sufficient understanding of non-formal land rights, land procurement proposals for the public infrastructure upgrades can be frustrated by the individual or group claims on the land, making the service provision impossible in informal settlements