Project 4: Operationalizing One Health in Ingwavuma Community: Developing Transdisciplinary Methodology (South Africa)
Principal Investigator: Professor Moses J. CHIMBARI, College of Health Sciences, University of Kwazulu-Natal, Durban, South Africa
This project is a follow up from an earlier collaboration made possible by the TDR IDRC Research Initiative on VBDs and Climate Change, with research projects in South Africa, Kenya, Tanzania and Cote d'Ivoire. The collaboration was aimed at reducing population health vulnerabilities and increasing resilience against vector borne diseases (VBD) risks under climate change conditions in Africa. The South African project branded as MABISA (Malaria and Bilharzia in Southern Africa), was implemented in Botswana, Zimbabwe and South Africa. In addressing the overall theme of the TDR IDRC Research Initiative, the MABISA project identified research gaps that impeded control, prevention and elimination of malaria and schistosomiasis in the 3 countries, in the context of climate change. The Ecohealth approach was the main approach applied by the collaborating countries.
In 2019 TDR/WHO convened a meeting to discuss possibilities for using a One Health approach to conduct implementation research building on the experiences and outcomes of the initial collaboration referred to above. This approach entailed bridging health and environment, locally as well as globally and brings the perspective of zoonoses. The current project was therefore developed to leverage on the experiences of the MABISA project to contribute towards a One Health Scorecard introduced at the Brazzaville consultation meeting (November 2019).
This current project is located in South Africa (see Figure 3) and is being implemented in the context of KwaZulu-Natal Ecohealth Programme (KEP). It draws from lessons of the MABISA project across the 3 countries (Botswana, Zimbabwe and South Africa). The outcomes of the project will feed into the collaborative overall One Health project involving South Africa, Kenya, Tanzania and Cote d'Ivoire.
To ensure that the knowledge and resources generated during the initial TDR IDRC Research Initiative, TDR with Global Health International Group (GHGI) sought to 1) strengthen a network of Transdisciplinary Scientist-practitioners and facilitate production of a series of publications and presentations for research, education, and policy forums and 2) facilitate development of a Standardized One Health Scorecard on the basis of experiences and knowledge generated from the previous program.
As part of the network, the main goal of the South African project is to address capacity development, knowledge and learning and threat management for operationalizing One Health in South Africa.
Summary of achievements:
Main objective: To address capacity development, knowledge, learning and threat management for operationalizing One Health in South Africa.
Specific objective 1.To enhance and develop capacity at different levels for operationalizing One Health.
The KwaZulu-Natal Ecohealth Program (KEP) has been working in Ingwavuma since 2014, when the MABISA (Malaria and Bilharzia in Southern Africa) project was initiated. Key to KEP success has been the establishment of a governance structure and operations strategy that involves the community. A 12-member Community Advisory Board (CAB) comprising of one headperson, two community leaders, three school board members, three community care givers and three ordinary community members established at the inception of the program is functional to date. KEP’s field operations were carried out by researchers and Community Research Assistants (CRAs). The presence of the CAB and CRAs had been instrumental in promoting the concept of community change makers for prevention and control of vector borne diseases including zoonosis. In addition, CRAs played a key role in data collection.
Data Collection. Over the years the KEP team had invested in equipping CRAs with both knowledge and skills to conduct research. The CRAs were trained to attain the required skills for the field work. The periodic training given to CRAs includes ethics, epidemiology of malaria and schistosomiasis, basic research methods, quality control and technical skills for data collection. The CRAs were responsible for assisting the KEP team in recruiting study participants, obtaining consent, and for data collection.
These CRAs were experienced in collecting both qualitative and quantitative data through conducting interviews, administering questionnaires, and using KoBo collect, a free open-source tool used to collect data in the field using mobile devices. CRAs also assisted in conducting focus group discussions in the local language. CRAs had also been taught how to conduct sample collection and identify vector snails and mosquito larvae. They are also knowledgeable with parasitology as they are actively involved in specimen collection and screening.
Community Change makers. KEP’s community change makers initiative was championed by teachers and primary school learners as well as CRAs. Teachers and learners, through their respective schools were involved in edutainment activities that facilitate health education in the community. Schools were engaged in an annual performance art competition where learners were actively involved in the dissemination of research results through performances. Participating schools integrated indigenous theatrical modes and everyday practices providing a rich source of familiar metaphors that aided in the construction of meaningful facilitating understanding and research uptake.
CRAs helped in developing trust between the community and the researchers, as they were familiar with the local people. Their presence allowed KEP to stay informed about the community’s perception of the project and to remain socially and culturally relevant. CRAs maintained the visibility of KEP and were the boundary partners between the research team and the community.
Specific objective 2.To co-develop a theory of change with stakeholders to easily identify priority areas for research and intervention.
This project had engaged with the various community structures and fora in an effort to co-develop a theory of change (see FIGURE 4).
Community Advisory Board. The community advisory board was composed of senior community members and village headpersons selected from the villages where the project operates. There were two representatives from each village. The role of the CAB was to provide advice and guidance on how project activities are done in the community. Before research programs were rolled out in the community, the researchers sat down with the CAB members to discuss key areas where the research can be effective. The CAB members had helped to identify individuals in the community who can be involved in the research work. The CAB also linked the researchers to the community and their main role was to negotiate with the community on behalf of the researchers and provide buy-in from the community. Apart from providing guidance, they mobilized the community on behalf of the researchers. Their role had allowed the project activities to be recognized and accepted by the community.
Engagement with Indunas (local traditional leadership). As part of development of new projects within KEP, Indunas (local traditional leaders) and representatives of the CAB members (Village Heads) were often invited to participate in workshops conducted to map out strategies and plan for research activities. These meetings had been critical in helping the leaders to understand the various research projects being implemented in the area, the purpose of the studies and the data to be collected. The presence of the village headpersons and CAB members in the past meetings created an opportunity to involve them in the planning and preparation for the projects currently running in the study area.
Community research assistants. The CRAs had been working with the project since the MABISA initiative. The CRAs were involved in the planning and execution of household surveys, school screening activities and sampling of snails in water bodies. They had also assisted in translating and localizing surveys: by providing guidance on how questions may be asked using the language and context which the local people understand.
Specific objective 3. To identify hurdles to full empowerment of communities through a co-development of an M&E framework.
Through community engagement and involvement at the research site, several health challenges that exist in the community were identified as impeding full empowerment of communities. These challenges include the COVID-19 pandemic, mental health issues, malaria incidences, non-communicable diseases, malnutrition and water, sanitation and hygiene challenges.
COVID-19. The COVID-19 pandemic had profoundly affected lives of the research teams and the communities. Isolation, contact restrictions and economic shutdown introduced in the country have affected knowledge and learning processes resulting in threatened mental health of children, youth and adults. Other negative health effects brought by COVID-19 were anxiety and reduced opportunities for stress regulation and management.
Mental health challenges. Mental health issues had been identified in the research community as one of the increasing/persisting health challenges. People living with mental illness or substance use disorders were more exposed to healthy living risks (Marrero et al., 2020). Their immune systems get weaker and usually fail to adhere to medication or treatment of their existing illnesses, e.g., HIV/AIDS. The project had identified a critical need to invest in mental health education and more importantly, making interventions and services accessible at the community research site.
Malaria. From 2014, the MABISA project focused on malaria. One of the studies conducted assessed individual and household malaria risk factors among women in a South African village (Mutegeki, Chimbari & Mukaratirwa, 2017). Post MABISA project, the prevalence of malaria in the community has declined, however, the health challenges associated with malaria persist in the community posing a risk to resurgence of malaria.
Non-communicable diseases (NCDs). Some work on NCDs focusing on the “Prevalence, awareness, perceptions and burden of cardiovascular disease risk factors in Ingwavuma, KwaZulu-Natal indicated that there is a general need to extend healthcare provision in order to ensure improved access especially for cardiovascular care (Chikafu & Chimbari, 2019). During some feedback sessions/meetings with the community, it became clear that there is also a need to expand studies related to NCDs, e.g., negative effects caused by some common NCDs in the research community, e.g., decreased libido/sexual activity especially by diabetic men in the community.
Malnutrition. Healthy diet consumption continued to be a challenge in the research community resulting in stunting among children which had a negative effect on children’s growth and learning processes. There is currently an ongoing study focusing on determinants of malnutrition in a schistosomiasis endemic area within the study site. This study will assess how the impacts of schistosome and STH infections on children are exacerbated by nutritional deficiencies.
Water, sanitation and hygiene (WASH). This project also worked with the community from rural KwaZulu-Natal to conduct studies on WASH practices in the community especially relevant to schistosomiasis prevention (Mulopo & Chimbari, 2021). Most areas/villages in the research community do not have easy access to clean and adequate water. Lack of adequate and clean water supply exposes community members to an increased risk to poor hygiene and sanitation related illnesses. One of the studies conducted indicated low attitudinal factors towards the use of safe water sources (Mulopo, Kalinda & Chimbari, 2020) signifying gaps in knowledge and learning for WASH practices in the research areas.
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