Prioritising and planning scale-up research projects targeting non-communicable diseases: a mixed-method study by the Global Alliance for Chronic Diseases upscaling working group.

INTRODUCTION: Governments must scale-up evidence-based interventions to reduce the burden of non-communicable diseases (NCDs). Implementation research can help develop contextually appropriate strategies and optimise interventions for scale-up. We aimed to determine the priorities of the Global Alliance for Chronic Diseases (GACD) 2019 funding round for scale-up research targeting NCD interventions. The research questions were: (a) What was the purpose of the call and what were the specific issues considered by funders when supporting the selected projects? (b) How did the selected research projects align with the objectives of GACD scale-up call? METHODS: We undertook a mixed-methods study to examine the projects funded by the GACD in 2019. We completed semistructured interviews with representatives from 5 out of 8 funding agencies and complemented this by reviewing project documents from 21 (78%) of the 27 funded studies. A literature review of scale-up frameworks informed the interview guide and data extraction template. The transcripts were open-coded using thematic analysis to identify critical issues for funders. Data were extracted to identify the common elements considered when planning, implementing and evaluating interventions for scale-up. RESULTS: Interviews with the funders revealed three enabling themes related to scale-up: local research priorities (contextualisation through engagement), capacity building (developing knowledge base) and connections (networking opportunities). We further identified that timelines (more flexibility) and equity (funding low-income and middle-income researchers) could be considered for future funding investments. Multidisciplinary international research teams led the development of diverse studies to address funder's priorities. The detailed plans included a range of implementation frameworks to help develop contextual scale-up strategies. CONCLUSIONS: Fundamental to NCD scale-up research are (1) funding opportunities that reflect the complexity and time necessary to enable contextualisation; (2) investment in building multidisciplinary research capacity and leadership and (3) better networking to encourage cohesive action and align NCD-related scale-up research activities globally.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Obstacles to integrated pest management adoption in developing countries.

Despite its theoretical prominence and sound principles, integrated pest management (IPM) continues to suffer from anemic adoption rates in developing countries. To shed light on the reasons, we surveyed the opinions of a large and diverse pool of IPM professionals and practitioners from 96 countries by using structured concept mapping. The first phase of this method elicited 413 open-ended responses on perceived obstacles to IPM. Analysis of responses revealed 51 unique statements on obstacles, the most frequent of which was "insufficient training and technical support to farmers." Cluster analyses, based on participant opinions, grouped these unique statements into six themes: research weaknesses, outreach weaknesses, IPM weaknesses, farmer weaknesses, pesticide industry interference, and weak adoption incentives. Subsequently, 163 participants rated the obstacles expressed in the 51 unique statements according to importance and remediation difficulty. Respondents from developing countries and high-income countries rated the obstacles differently. As a group, developing-country respondents rated "IPM requires collective action within a farming community" as their top obstacle to IPM adoption. Respondents from high-income countries prioritized instead the "shortage of well-qualified IPM experts and extensionists." Differential prioritization was also evident among developing-country regions, and when obstacle statements were grouped into themes. Results highlighted the need to improve the participation of stakeholders from developing countries in the IPM adoption debate, and also to situate the debate within specific regional contexts.

Making sense of agrobiodiversity, diet, and intensification of smallholder family farming in the Highland Andes of Ecuador.

Methods are needed for helping researchers and farmers to interactively describe and analyze local practices in search of opportunities for improving health, environment, and economy. The authors worked with smallholder family farmers in five Andean villages in Ecuador to apply participatory four-cell analysis (PFCA) in characterizing agrobiodiversity. Margelef and Shannon indices examined ecological richness and evenness, and a simplified 24-hour dietary recall characterized food consumption. Cross-analysis tested interactions among agrobiodiversity, farm size, and diet. Overall trends appeared to work against sustainable intensification, with notable heterogeneity and positive deviance found in the practices of relatively smaller enterprises, representing a potential resource for sustainable intensification. The suite of methods was determined useful for initiating researcher-farmer explorations of promising innovation pathways.

Assessment and characterization of the diet of an isolated population in the Bolivian Andes.

OBJECTIVES: The goal of this research is to characterize the composition and nutrient adequacy of the diets in the northern region of the Department of Potosí, Bolivia. Communities in this semiarid, mountainous region are isolated and impoverished having the highest rates of child malnutrition and under-five mortality in the Americas. METHODS: A total of 2,222 twenty-four-hour dietary recalls were conducted in 30 communities during May and November 2006 and May and November 2007. Food composition data were compiled from diverse published sources and integrated with the recall data to estimate intakes of energy, protein, fat, carbohydrates, and seven micronutrients. Diets were characterized in terms of food sources, seasonality, and nutrient adequacy. RESULTS: The diet relies heavily on the potato and other tubers (54% of dietary energy) and grains (30% of dietary energy). Although crop production is seasonal, off-season consumption of chuño helps to minimize seasonal fluctuations in dietary energy intake. Despite relative monotony, intakes of iron, vitamin C, most B vitamins, and vitamin A in adults are probably adequate; riboflavin, calcium, and vitamin A intakes in children are low. Nevertheless, extremely low dietary fat intakes (approximately 3-9% of dietary energy from fat) likely prevent adequate absorption of fat-soluble vitamins as well as lead to deficiencies of essential fatty acids. CONCLUSIONS: Dietary inadequacies, especially of fats, may explain much of the poor health observed in northern Potosí. An improved diet may be possible through increasing production and intake of local fat-rich food sources such as small animals.

Reducing pesticide exposure and associated neurotoxic burden in an Ecuadorian small farm population.

The contribution of community-based interventions, including farmer field schools (FFSs) in integrated pest management (IPM), to reducing pesticide exposures and associated neurotoxic burden among small-farm families in Ecuador was assessed in three Andean farming communities in a co-design of targeted action-research. Baseline questionnaire surveys elicited pesticide-related knowledge, practices, and exposure and neurobehavioral assessments were done using an adapted WHO battery. Pesticide applications on plots farmed by FFS versus non-FFS participants were compared. A year later, repeated surveys of participating households (n = 29) and neurobehavioral testing of individuals (n = 63) permitted comparisons of pre- and post-intervention values. The FFS graduates applied pesticides on their plots less frequently (p = 0.171). FFS households had increased pesticide-related knowledge of labels and exposure risk factors (both p < 0.004), better pesticide-handling practices (p < 0.01), and less skin exposure (p < 0.01). Neurobehavioural status had improved, particularly digit span and visuo-spatial function, resulting in overall z-score increases. Thus, community interventions reduced pesticide use, reported skin exposure, and neurotoxic burden among smallholder farm families.

Pesticides and health in highland Ecuadorian potato production: assessing impacts and developing responses.

Pesticide use in highland Ecuador is concentrated in the high-risk, commercial production of potatoes. Small farm families experience considerable exposure and adverse health consequences. The authors describe a three-pronged strategy to reduce health impacts: 1) a community-based process of education and provision of personal protective equipment to reduce exposure; 2) farmer field schools to increase agro-ecosystem understanding and to reduce pesticide use; and 3) policy interventions to restructure incentives and to reduce availability of highly toxic insecticides. They discuss the challenges faced by each and the ongoing need for integrated interventions both to reduce adverse pesticide health impacts in the developing world and to promote sustainability of agricultural production in highland ecosystems.