Healthy animals, healthy people: lived experiences of zoonotic febrile Illness in northern Tanzania

In the recognition that 75 percent of all emerging human infectious diseases in the past three decades originated in animals, many prominent veterinary and human health scientists have subscribed to the ‘One Health’ approach as a basis for redressing human diseases, animal diseases and environmental degradation worldwide (Rock et al., 2009). At its core, ‘One Health’ recognises the interconnectedness of humans, animals and the environment and thus calls for cross-sectoral, collaborative and integrative approaches to reducing disease burdens that arise at this interface. However, while the approach appears to be all encompassing in terms of interdisciplinary science, scant attention has been paid to the relationship between disease and society (Dzingirai et al., 2017). Endemic zoonoses, for example, disproportionately affects those in underprivileged communities and has significant impacts on rural livelihoods (Halliday et al., 2015). These diseases highlight how complex systems of health, poverty and politic collide, resulting in ‘structural violence’ (Galtung, 1969) and avoidable suffering for those who are already marginalised. Through adopting a mixed methods ethnography, this thesis offers insight into the lived experiences of livestock and human febrile illness (many of which are zoonotic) in an agropastoral community in northern Tanzania. I trace, in detail, the health seeking strategies undertaken to remedy illness, from recognition of symptoms through to engaging with public and veterinary health systems. By adopting a biosocial approach to this research, I am able to scrutinise the ways in which health-related behaviours are socially mediated. In doing so I uncover how ‘structural violence’ (Galtung, 1969) is deeply embedded within health systems and ultimately embodied by livestock keepers when pursuing health care for themselves and their livestock. This thesis hopes to provide a more critical theorisation of health seeking by highlighting the ways in which animal and human illness is experienced within prevailing social, political and economic dynamics. This has the potential to contribute to social science scholarship within One Health by taking a more nuanced view of the material conditions in which people live that shape their ability to effectively pursue animal and human health and wellbeing

Activating Equitable Engagement: from research to policy (and back again): a report on dissemination activities for 'NIHR Global Health Research Group on estimating the prevalence, quality of life, economic and societal impact of arthritis in Tanzania'

This report details the dissemination outputs, stakeholder engagement events (herein referred to as ‘Engagement Activities’) and their underlying principles conducted by the NIHR Funded Project: NIHR Global Health Research Group on estimating the prevalence, quality of life, economic and societal impact of arthritis in Tanzania. Engagement activities were designed acknowledging that inequalities and injustices are writ large in the field of Global Health. Just as social, economic, political, racial and gendered inequalities impact individuals’ health experiences, we also recognise that these same inequalities can be reproduced and reinforced by institutions, organisations and (most pertinent to us) research groups purporting to tackle health issues (Büyüm et al. 2020). Engagement activities were therefore designed from a commitment to make Global Health more equitable, with the following interrelated principles underpinning all engagement efforts: i) the ethics of dissemination ii) valuing knowledges iii) decentering western voices iv) nurturing equitable relationships. As such, we paid close attention not only to what we did but how we did it, striving towards a goal of activating equitable engagement

“Using the same hand”: the complex local perceptions of integrated one health based interventions in East Africa

Background: Neglected Tropical Diseases (NTDs) such as soil transmitted helminths (STH) and human rabies represent a significant burden to health in East Africa. Control and elimination remains extremely challenging, particularly in remote communities. Novel approaches, such as One Health based integrated interventions, are gaining prominence, yet there is more to be learned about the ways in which social determinants affect such programmes. Methodology: In 2015 a mixed method qualitative study was conducted in northern Tanzania to determine community perceptions towards integrated delivery of two distinct healthcare interventions: treatment of children for STH and dog vaccination for rabies. In order to assess the effectiveness of the integrated approach, villages were randomly allocated to one of three intervention arms: i) Arm A received integrated mass drug administration (MDA) for STH and mass dog rabies vaccination (MDRV); ii) Arm B received MDA only; iii) Arm C received MDRV only. Principle findings: Integrated interventions were looked upon favourably by communities with respondents in all arms stating that they were more likely to either get their dogs vaccinated if child deworming was delivered at the same time and vice versa. Participants appreciated integrated interventions, due to time and cost savings and increased access to essential health care. Analysis of qualitative data allowed deeper exploration of responses, revealing why people appreciated these benefits as well as constraints and barriers to participation in integrated programmes. Conclusions/significance: An interdisciplinary One Health approach that incorporates qualitative social science can provide key insights into complex local perceptions for integrated health service delivery for STH and human rabies. This includes providing insights into how interventions can be improved while acknowledging and addressing critical issues around awareness, participation and underlying health disparities in remote pastoralist communities

Developing a logic model for communication-based interventions on Antimicrobial Resistance (AMR)

The importance of communication in enhancing people’s awareness and understanding of antimicrobial resistance (AMR) is consistently recognised in global and national action plans (NAPs). Despite this, there have been relatively few national AMR communication campaigns which use a structured approach to take account of the local context, encompass co-design with the target audience and use a logic model to help inform its design, implementation and evaluation. Designing a logic model for communication-based interventions can help map out the planning, resources, messaging, assumptions and intended outcomes of the campaign to maximise its impact, ensure it is fit for context and minimise any unintended consequences on individuals and society. Building on an AMR research project in Tanzania, Supporting the National Action Plan for AMR (SNAP-AMR), we co-designed the SNAP-AMR Logic Model with key stakeholders to implement AMR communication campaigns and related legacy materials to be employed in support of the Tanzanian NAP, but with broader relevance to a range of contexts. In developing the SNAP-AMR Logic Model, we reviewed relevant communication theories to create and target messages, and we considered behavioural change theories. We defined all key elements of the SNAP-AMR Logic Model as follows: (1) resources (inputs) required to enable the design and implementation of campaigns, e.g. funding, expertise and facilities; (2) activities, e.g. co-design of workshops (to define audience, content, messages and means of delivery), developing and testing of materials and data collection for evaluation purposes; (3) immediate deliverables (outputs) such as the production of legacy materials and toolkits; and (4) changes (outcomes) the campaigns aim to deliver, e.g. in social cognition and behaviours. The SNAP-AMR Logic Model efficiently captures all the elements required to design, deliver and evaluate AMR communication-based interventions, hence providing government and advocacy stakeholders with a valuable tool to implement their own campaigns. The model has potential to be rolled out to other countries with similar AMR socio-cultural, epidemiological and economic contexts

“If you do not take the medicine and complete the dose…it could cause you more trouble”: bringing awareness, local knowledge and experience into antimicrobial stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action

Contextualising health seeking behaviours for febrile illness: lived experiences of farmers in northern Tanzania

Understanding how people seek treatment for febrile illness can provide important insights into when care is sought and under what circumstances. This is includes examining how people engage with health facilities and the barriers to care they experience. However, a focus on individual actions runs the risk of overemphasising the agency of individuals to make apt health decisions while underestimating the ways which health behaviours are circumscribed by their place-specific social, historic and political contexts. Drawing on the experiences of approximately 100 farmers in a small livestock keeping community in northern Tanzania, this study uses biosocial theory of health to better understand how febrile illness is managed among individuals. The paper draws attention to the ways in which health decisions are mediated by individual, intrinsic and extrinsic health system factors. Some extrinsic factors (such as hospital user fees) are legacies of neoliberal healthcare reform policies which continue to have consequences for how people manage febrile illness in Tanzania. The findings highlight the need for considerations of health behaviours to look beyond the individual and to appreciate the role of the wider health landscape in influencing individual choice and agency when seeking treatment for illness

Using intersectionality to identify gendered barriers to health-seeking for febrile illness in agro-pastoralist settings in Tanzania

Background: Research has shown that gender is a significant determinant of health-seeking behaviour around the world. Gender power relations and lay etiologies of illness can influence the distribution of household resources, including for healthcare. In some rural settings in Africa, gender intersects with multiple forms of health inequities, from proximal socio-cultural factors to more ‘upstream’ or distal health system determinants which can amplify barriers to health-seeking for specific groups in specific contexts. Aim: We used an intersectionality approach to determine how women in particular experience gendered barriers to accessing healthcare among Maa and non-Maa speaking agro-pastoralists in northern Tanzania. We also explored lay etiologies of febrile illness, perceptions of health providers and rural health-seeking behaviours in order to identify the most common barriers to accessing healthcare in these settings. Methods: Ethnographic approaches were used to collect data between 2016 and 2018 from four Maa-speaking and two Swahili-speaking agro-pastoralist villages in northern Tanzania. Data on health seeking behaviours was collected through semi-structured questionnaires, in-depth interviews, focus group discussions and participant observation. Findings: The results primarily focus on the qualitative outcomes of both studies. We found that febrile illness was locally categorised across a spectrum of severity ranging from normal and expected illness to serious illness that required hospital treatment. Remedial actions taken to treat febrile illness included attending local health facilities, obtaining medicines from drug sellers and use of herbal remedies. We found barriers to health-seeking played out at different scales, from the health system, community (inter-household decision making) and household (intra-household decision making). Gender-based barriers at the household had a profound effect on health-seeking. Younger women delayed seeking healthcare the most, as they often had to negotiate with husbands and extended family members, including co- wives and mothers-in-law who make the majority of health-related decisions. Conclusion: An intersectional approach enabled us to gain a nuanced understanding of determinants of health-seeking behaviour beyond the commonly assumed barriers such lack of public health infrastructure. We propose tapping into the potential of senior women involved in local therapy-management groups, to explore gender-transformative approaches to health-seeking, including tackling gender-based barriers at the community level

A Critical Resource for Understanding Research Impact for Participatory International Research

Research impact has become an important concept in the Academy. Without careful and critical attention, this term can be applied in ways that risk imposing meaning upon a wide range of geographical, cultural, and disciplinary contexts. Layers of lived experience and learning can be overlooked and as such undervalued or misunderstood. Equally, assertions of impact can be imbued with assumptions that may not hold relevance outside of the dominant discourses in which they were developed. The provocations, explorations, and propositions that we present here are designed to support the development of more equitable, inclusive and sustainable approaches to research impact, particularly in international and interdisciplinary contexts. Available online and distributed free in hard copy

“If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble”: Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action