Strengthening capacity to research the social determinants of health in low- and middle-income countries: lessons from the INTREC programme.

BACKGROUND: The INDEPTH Training & Research Centres of Excellence (INTREC) collaboration developed a training programme to strengthen social determinants of health (SDH) research in low- and middle-income countries (LMICs). It was piloted among health- and demographic researchers from 9 countries in Africa and Asia. The programme followed a blended learning approach and was split into three consecutive teaching blocks over a 12-month period: 1) an online course of 7 video lectures and assignments on the theory of SDH research; 2) a 2-week qualitative and quantitative methods workshop; and 3) a 1-week data analysis workshop. This report aims to summarise the student evaluations of the pilot and to suggest key lessons for future approaches to strengthen SDH research capacity in LMICs. METHODS: Semi-structured interviews and questionnaires with 24 students from 9 countries in Africa and Asia were used to evaluate each teaching block. Information was collected about the students' motivation and interest in studying SDH, any challenges they faced during the consecutive teaching blocks, and suggestions they had for future courses on SDH. RESULTS: Of the 24 students who began the programme, 13 (54%) completed all training activities. The students recognised the need for such a course and its potential to improve their skills as health researchers. The main challenges with the online course were time management, prior knowledge and skills required to participate in the course, and the need to get feedback from teaching staff throughout the learning process. All students found the face-to-face workshops to be of high quality and value for their work, because they offered an opportunity to clarify SDH concepts taught during the online course and to gain practical research skills. After the final teaching block, students felt they had improved their data analysis skills and were better able to develop research proposals, scientific manuscripts, and policy briefs. CONCLUSIONS: The INTREC programme has trained a promising cadre of health researchers who live and work in LMICs, which is an essential component of efforts to identify and reduce national and local level health inequities. Time management and technological issues were the greatest challenges, which can inform future attempts to strengthen research capacity on SDH.

Introducing smoking cessation to Indonesian males treated for tuberculosis: The challenges of low-moderate level smoking.

There is a dearth of information about the smoking habits of people currently and formerly treated for tuberculosis (TB) in low- and middle-income countries (LMICs). In this paper we describe research carried out in Indonesia between 2007 and 2011 designed to investigate both the impact of TB-specific quit smoking messages in the TB clinic and at home, and shifts in patterns of smoking among those formerly treated for TB who continue to smoke. The results of a modest two-arm smoking cessation trial involving 87 patients undergoing Directly Observed Therapy Short course treatment (DOTS) for TB are presented. In one arm patients received a TB-specific quit smoking message delivered by doctors and a TB and smoking educational booklet and quit smoking guide. In the second, family support arm, patients also received on-going cessation messages delivered by family members trained to be DOTS supporters. The study followed patients twice during their six months of DOTS treatment and twice six months post treatment. Both arms of the study reduced rates of smoking during and following TB treatment significantly with 73% of patients in the doctor arm and 71% in the family support arm remaining quit at the end of the treatment (month 6). When complete abstinence at six months after treatment was taken as a primary outcome measure, no statistical difference was found in the effectiveness of the two arms of the intervention. Notably, 67% of higher-level smokers at baseline and 33% of low-moderate level smokers at baseline quit entirely. Many of those who resumed smoking did so at low-moderate levels (<6 cigarettes a day). Eighty-four percent of patients who quit during treatment maintained their abstinence six months after treatment, 13% resumed smoking at a low-moderate level (<6 cigarettes), and only 3% resumed smoking at a higher level. A purposeful sample of 15 patients who shifted from heavy smoking (20-40 cigarettes per day) to low-moderate levels of smoking post treatment were followed for an additional 12 months. We report on their ability to sustain lower levels of smoking and self-perceived smoking status given their dramatic reduction in cigarette consumption. This is the first study of low-moderate level smoking among patients formerly treated for TB conducted anywhere in South-East Asia.

Community response to avian flu in Central Java, Indonesia.

This pilot study suggests that it is more appropriate to think of avian flu as a bio-social and bio-political challenge for Indonesia than merely an epidemiological challenge involving a disease of zoonotic origin. Our examination of popular perceptions of avian flu in Central Java reveals important differences of opinion about which types of fowl are responsible for avian flu transmission and the degree of risk H5N1 poses to humans. The opinions of backyard farmers and commercial poultry farmers are motivated by different forms of practical logic and are differentially influenced by media accounts, government education programmes, foreign aid and rumours about who stands to profit from the disease. Rumours reflect collective anxieties about globalization, the agenda of big business and the trustworthiness of the national government. We also illustrate how a commodity chain analysis can assist in the identification of different stake-holders in the informal and formal poultry industries. The position of each stake-holder needs to be considered in any comprehensive investigation of avian flu. An economic analysis of the capital investment of stake-holders provides insight into how each responds to government directives about the reporting of dead chickens, vaccinating birds etc. Finally, we call for research on avian flu preparedness attentive to Indonesia's de-centralized form of political rule and the social organization of communities so that clear lines of communication and command can be established and mutual assistance mobilized.