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Healthcare worker interviews community member on impact of HIV in their community. Credit © 2008 Frederic Courbet for International AIDS Vaccine Initiative (IAVI)

PAVE - The Politics and Anthropology of Violence and Epidemics

The PAVE team are an anthropological led team including social scientists, political theorists, epidemiologists, and modellers. Working in an innovative cross-disciplinary approach we address two public health problems: violence and epidemics and the intersections between them. 

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About

The Politics and Anthropology of Violence and Epidemics (PAVE) team are an anthropological led team including social scientists, political theorists, epidemiologists, and modellers. The team is based at the London School of Hygiene and Tropical Medicine, as well as the University of Oxford, Institute of Development Studies, Harvard University and the World Health Organisation.

Research

Our work draws on debates in the anthropology of epidemics and humanitarian emergencies; social science perspectives on medical research; anthropology of violence within conceptual framing of  the future (uncertainty, hope, destiny, anticipation) and of power (structure, agency, bio-citizenship). We argue for the importance of anthropological perspectives in interventions to reduce violence and in biomedical responses to epidemics (including clinical trials and medical humanitarian response). We are at the forefront of debates on the importance of engaging with beneficiaries in the development and conduct of public health research.

About
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The Politics and Anthropology of Violence and Epidemics (PAVE) team are an anthropological led team including social scientists, political theorists, epidemiologists, and modellers. The team is based at the London School of Hygiene and Tropical Medicine with collaborations at University of Oxford, Anthrologica and the College of Medicine and Allied Health Sciences (University of Sierra Leone), Sierra Leone Urban Research Centre (SLURC), Centre for Applied Policy Research and Innovation Sierra Leone (CAPRI) (African collaborations). Working in an innovative cross-disciplinary approach we address two public health problems: violence (structural and interpersonal) and epidemics (HIV, Ebola and COVID-19) and the intersections between them. 

Epidemics and experiences of violence tend to be studied as separate issues, leading to analytical blindspots on the intersections between them. Emphasis on individual behaviour or attitudes in outbreak response measures, for example, often obscures how histories of structural violence and conflict impact the ways in which nations, communities and individuals can respond to and prepare for epidemics. Similarly, patterns of disease transmission and the socio-economic effects of epidemic control interventions have significant implications for the incidence and nature of interpersonal and political violence.

Our work draws on debates in the anthropology of epidemics and humanitarian emergencies; social science perspectives on medical research; anthropology of violence within conceptual framing of  the future (uncertainty, hope, destiny, anticipation) and of power (structure, agency, bio-citizenship). We argue for the importance of anthropological perspectives in interventions to reduce violence and in biomedical responses to epidemics (including clinical trials and medical humanitarian response). We are at the forefront of debates on the importance of engaging with beneficiaries in the development and conduct of public health research.

In our research we aim to:

  1. Understand the political, economic, social and historical conditions that lead to violence and epidemics, and the relationship between them, in specific contexts
  2. Explore local narratives and experiences of violence and epidemics to inform public health interventions 
  3. Develop effective ways in which to engage with communities and publics around research, public health response and policy
  4. Develop innovative and truly interdisciplinary approaches to produce holistic analyses of violence and epidemic dynamics and to contribute to developing practical solutions 
  5. Develop and build-on pre-existing technologies for collection and analysis of qualitative data in challenging settings
Who we are
Team Block
LSHTM

Shelley
Lees

Professor

Luisa
Enria

Assistant Professor

Alex
Bowmer

Research Fellow

Mark
Marchant

Research Fellow

Rose
Burns

Research Fellow

Hana Rohan

Assistant professor

Chrissy
Roberts

Associate Professor

Rosalind
Eggo

Associate Professor

Gillian
Mckay

Research Degree Student

Anthony
Mansaray

Research Fellow

Samuel Boland

Research Degree Student

Susan Kelly

Research Fellow
Oxford
Samantha Vanderslott

Samantha Vanderslott

University Research Lecturer
Myfanwy James

Myfanwy James

Departmental Lecturer
WHO
Hannah Brindle

Hannah Brindle

Research Fellow
IDS
Megan Schmidt-Sane

Megan Schmidt-Sane

Postdoctoral Researcher
Harvard
Lys Alcayna-Stevens

Lys Alcayna-Stevens

Research Fellow
Research
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We conduct interdisciplinary research on violence and epidemics, and the intersections between them, taking a number of perspectives including: political economy, feminist and medical anthropology, One Health, health/help seeking, decolonising knowledge and and community-led research. We have a growing research portfolio that has two overarching themes (Epidemic Preparedness and Response and Gender-based and Intimate Partner Based Violence). Given the need to ensure that social science research informs policy in urgent public health measures to address violence and epidemics we are members of the following groups.

AVID

Shelley Lees, Luisa Enria, Alex Bowmer, Mark Marchant, Clarissa Simas, Samantha Vanderslott, Lys Alcayna-Stevens, Hana Rohan

Project summary​

Project AViD (Anthropological Exploration of Facilitators and Barriers to Vaccine Deployment and Administration During Disease Outbreaks), headed by Shelley Lees, is working across DRC, Sierra Leone, Brazil, India and Uganda, adopting both a top-down and bottom-up approach to exploring vaccine acceptance.

This project takes a critical anthropological approach to exploring what actions can be taken to optimise vaccine acceptance during a disease outbreak. Whilst some countries already face logistical challenges to vaccine deployment and administration, these system weaknesses are exacerbated during times of disease outbreaks. In addition to access challenges, some populations have underlying distrust in national and international bodies that provide vaccines, which can also amplify in times of emergencies, as seen in the recent Ebola and Zika outbreaks. Rumours and misinformation are also commonly spread in times of outbreaks, especially when the diseases are unfamiliar, or there is an absence of information available.

Background information

Recent outbreaks have made clear that inadequate consideration of social, cultural, political, and religious factors in humanitarian responses has consequences for the effectiveness and community acceptability of response activities. A growing number of studies have focused on the historical, social, cultural and political determinants of vaccine acceptance, and have highlighted the specificities of these dynamics during emergencies. Whilst these theories are useful to help understand potential issues for vaccine deployment and administration during an outbreak, there are gaps in the evidence, particularly relating to acquiring evidence in real-time.

Given the wider range of disease and contexts, there is a need to understand different of perspectives about vaccines and outbreaks, including the political and economic factors that determine whether vaccines can be deployed effectively in an emergency situation, health system perspectives, which are closely tied to cultural, policy, and historical developments in how provision is organised, as well as local systems of knowledge to identify community perceptions surrounding vaccine use. Finally, given that many diseases are zoonotic, understandings of community experiences of vaccination in both human and animal health are needed. This study sets out to address these gaps through qualitative, comparative research across five different countries to explore the facilitators and barriers to vaccine deployment during outbreaks.

Rather than focusing on one disease/vaccine or one context, this study will explore an “ecosystem” of vaccine deployment drawing on different perspectives in low-income contexts and for the poorest in middle-income contexts. Using a multiple-case study approach and a mix of qualitative and ethnographic methods Including key stakeholder interviews, document analysis and participant observation, the project will ensure insights into the complex web of factors that determine countries’ ability to deploy vaccines during an outbreak. Each case study aims to shed light on different factors that determine preparedness for emergency vaccine deployment.

The first case study will focus on Sierra Leone and will explore the political and economic factors that shape the feasibility of deploying vaccines in an emergency scenario drawing on lessons learned from Ebola. The second case study will investigate healthcare systems’ responses to vaccine controversies using past public vaccine controversies in India as a basis for enquiry. The third case study will look at the construction of local knowledge around vaccines through an exploration of the use of human and veterinary pharmaceuticals in rural Uganda. The fourth case study will study the impact of the Zika outbreak on public trust and vaccine hesitancy in Brazil, in order to assess how an outbreak context shapes vaccine confidence. The fifth case study investigates local perspectives on the experimental vaccine deployment during an epidemic, by conducting longitudinal ethnographic research in the immediate aftermath of the 2018 Ebola outbreak in Equateur Province, Democratic Republic of the Congo. A final potential case study will be provided through collaboration with the Public Health Rapid Support Team, who, if deployed during the time of the project, will investigate vaccine confidence and hesitancy in the realistic scenario of an ongoing epidemic. In 2022 we added a further case study in Tanzania. This extra case study will contribute to understanding political economic factors and health systems perspective and community perceptions.

Building trust in epidemic response

Project summary

The provinces of North and South Kivu in eastern Democratic Republic of the Congo (DRC) have suffered from decades of war and humanitarian crises (Bompangue et al., 2009). On 1 August 2018 an outbreak of Ebola virus disease (EVD) was declared in North Kivu province (World Health Organisation, 2018). By the end of the epidemic on 25 June 2020, there had been 3470 cases and 2287 deaths with over 300,000 people vaccinated using the rVSV-ZEBOV-GP vaccine (World Health Organisation, 2020a). However, the outbreak response was complicated by violence and mistrust amongst the community (Moran, 2018, Centre for Infectious Disease Research and Policy, 2019b). A Public Health Emergency of International Concern was declared on 17 July 2019 (World Health Organisation, 2019a).

Research from the outbreak of EVD in Sierra Leone (2014-2016) suggested that compliance with public health interventions to prevent or cure EVD is influenced by public trust in the healthcare system and the understanding of the transmission risk of EVD in addition to the long-term effects of violence (Nuriddin et al., 2018, Betancourt et al., 2016). During the 2018-2020 EVD epidemic, it was thought that multiple factors contributed to the community mistrust in aid organisations,  including the rapid response to the outbreak in contrast to the long-term failure to protect civilians from conflict (Vinck et al., 2019), the limited assistance with access to basic healthcare, water and shelter and support for other ongoing outbreaks including measles and cholera (Arie, 2019). Research from Beni and Butembo showed that over a quarter of study participants did not believe that Ebola was real which resulted in a decreased likelihood of seeking formal healthcare or undertaking preventative measures including the acceptance of vaccines (Vinck et al., 2019). Two assessments of understanding of the epidemic in Goma and Beni, conducted by Translators without Borders found that women and older people in particular, did not fully understand the risk communication materials and community health workers faced difficulties in translating information on EVD to local languages (Translators without Borders, 2019a, 2019b).

In addition to the difficulties with mistrust, it is known that population movements can result in the spread of a pathogen to areas which were previously disease free (Kraemer et al., 2019). Travel across international borders and into cities may have played a role in the magnitude of the EVD outbreak in West Africa in 2014-2015 (World Health Organisation, 2019b). Within eastern DRC, Ebola moved between different health zones over the course of the epidemic (World Health Organisation, 2019c) and there is a high risk of cross-border spread from the DRC to neighbouring countries (Gostin et al., 2019) with recent cases in Uganda (World Health Organisation, 2019d) and Goma, DRC which borders Rwanda (World Health Organisation, 2019e).

The response faces significant challenges relating to effective health communication, surveillance (including identifying reasons for high rates of nosocomial transmission) and in reframing what has so far been a vertical response to consider (mis)trust in the wider health system (Vinck et al., 2019). Political instability exacerbates the challenge of engaging communities (Betancourt et al., 2016), highlighting the need to effectively map trusted sources of (formal and informal) authority. The intensity of the epidemic has increased and many people are no longer seeking care (International Federation of the Red Cross (IFRC), 2019) which is of particular concern due to porous borders between DRC and Uganda (Bedford, 2018, Storer and Pearson, 2019) and Rwanda (Lamarque et al., 2019).

As a result of these factors, Uganda has been undertaking activities to prepare for the importation of EVD since 7 November 2018. These include the set-up of Ebola Treatment Unit in the districts bordering North Kivu and Ituri, vaccination of health and frontline workers in areas at risk, community education and disease monitoring (World Health Organization, 2019d). However, there is a need to conduct research to better understand community trust in border districts in addition to movement patterns and risk of importation and potential geographical spread of the virus. This collaborative multi-site protocol was submitted under an emergency fund for Ebola by CDC to address these issues. 

Anthropology of Ebola Vaccine Trials in Sierra Leone and the Democratic Republic of Congo

Luisa Enria, Anthony Mansaray, Rose Burns, Myfanwy James, Shelley Lees

We are conducting long-term anthropological research and a wide range of social science studies alongside Ebola vaccine trials in Sierra Leone and DRC. Our multifaceted studies are exploring understand vaccine and trial acceptability and outbreak preparedness.by conducting in depth social science research (anthropology). This research has examined understandings and experiences of Ebola and vaccines, as well as perspectives of the vaccine and the concerns and rumours surrounding the trials as well as rumours, and concerns in Sierra Leone, and the Democratic Republic of Congo.

Projects

EBOVAC-Salone

As part of the EBOVAC1 consortium we are conducting anthropological research alongside the EBOVAC Salone trial in Kambia, Sierra Leone. In Kambia, this research, led by Luisa Enria and Shelley Lees, has involved in-depth anthropological research with participants and local communities to explore acceptability of vaccines and the trial itself. We have taken an in-depth critical perspective to explore broader political economy questions of vaccine trials and future vaccine deployment.

  • Lees S & Enria L (2020) Comparative Ethnographies of Medical Research: Materiality, Social Relations, Citizenship and Hope in Tanzania and Sierra Leone. International Health (Special Issue: Spotlight on Global Health Research)
  • Enria L & Lees S (2018) Citizens, Dependents, Sons of the Soil:  Defining Political Subjectivities through Encounters with Biomedicine during the Ebola epidemic in Sierra Leone Medical Anthropology Theory
  • Tengbeh, A.F. ; Enria, L. ; Smout, E. ; Mooney, T. ; Callaghan, M. ; Ishola, D. ; Leigh, B. ; Watson-Jones, D. ; Greenwood, B. ; Larson, H. ; Lees, S. ; "We are the heroes because we are ready to die for this country": Participants' decision-making and grounded ethics in an Ebola vaccine clinical trial. Soc Sci Med (2018) 203:35-42; DOI: 10.1016/j.socscimed.2018.03.008; PMID: 29544144 Open Access
  • Enria, L. ; Lees, S. ; Smout, E. ; Mooney, T. ; Tengbeh, A.F. ; Leigh, B. ; Greenwood, B. ; Watson-Jones, D. ; Larson, H. ; Power, fairness and trust: understanding and engaging with vaccine trial participants and communities in the setting up the EBOVAC-Salone vaccine trial in Sierra Leone. BMC Public Health (2016) 16(1):1140; DOI: 10.1186/s12889-016-3799-x; PMID: 27821112 Open Access
PREVAC

The PREVAC study is a large, international clinical trial which in Sierra Leone is sponsored by the London School of Hygiene & Tropical Medicine (LSHTM). PREVAC has been designed to gather some of the missing data on the three vaccine strategies. The study is evaluating the speed, intensity and duration of the immune responses generated by the vaccine strategies, as well as the safety and tolerability of the Ebola vaccines, particularly in children. Read more about our vaccine trial.

Led by Luisa Enria and Shelley Lees social science research at the trial site in Mambolo is exploring acceptability of vaccines and the trial itself by participants, including children, as well as the local community. We have taken an in-depth critical perspective to explore broader political economy questions of vaccine trials and future vaccine deployment.

PREVAC-UP

The project PREVAC-UP is built around the PREVAC consortium and its main objective is to evaluate the long-term safety and the durability immune responses of three different Ebola vaccine regimens previously tested by the consortium for 5 years after vaccination, as well as to provide a trans-national platform for social and health science research, and sustain capacity building and training of scientists in the four participant African countries (Guinea, Liberia, Mali and Sierra Leone).

A social science work package led by Shelley Lees and Rose Burns is collaboration with colleagues at INSERM, COMAHS (Sierra Leone), CNFRSR (Guinea), NPHIL (Liberia), USTTB (Mali) is collating evidence from ongoing social science research in the EBOVAC-Salone and the PREVAC trials described above. This research has revealed issues of power, fairness and trust surrounding the recruitment of participants into Ebola vaccine trials, which link to political and cultural concerns as well as participant’s motivations to take part in the trial was based on altruism, sacrifice, curiosity, and hope about the vaccine. Drawing on this experience this work package will involve expanding the social science activities to explore:

  1. Different models of community engagement at each site;
  2. participant experiences of vaccine development and the clinical trials; and
  3. the longer term impact of epidemics on people’s lives, and their experiences of epidemic responses as well as their understandings and experiences of health care
EBOVAC 3 Sierra Leone

EBOVAC3 is running clinical trials to gather safety and immunogenicity data on a two-dose Ebola vaccine regimen in infants in Sierra Leone and Guinea; as well as health care workers in an area affected by Ebola in the Democratic Republic of Congo (DRC). It will also follow up participants who received the vaccine regimen in the EBOVAC-Salone trial in Sierra Leone to assess the safety and immunogenicity of the regimen in the longer term

As part of the EBOVAC 3 consortium a social science work package is being conducting in three countries (Sierra Leone, Guinea and DRC) focussing on outbreak preparedness in order to garner recommendations for future responses to outbreaks. These studies will explore the legacy of the EBOVAC trial, future epidemic preparedness and community surveillance, perceptions of vaccination and vaccination strategies, and social network and contact pattern dynamics. a group of studies on preparedness. This includes exploring community experiences and perceptions of previous disease outbreaks, and perceptions and experiences of different Ebola vaccine deployment in three countries (Sierra Leone, Guinea and DRC) in order to garner recommendations for future responses to outbreaks. 

The Sierra Leone based research is led by Luisa Enria, Anthony Mansaray, Rose Burns and Shelley Lees (and formally Shona Lee) and includes the following components:

Legacy of the EBOVAC-Salone Trial

We are examining is the economic, infrastructural, and social impact of the EBOVAC-Salone trial in Kambia to understand the material and social legacies of the trial. This study aims to capture and preserve the institutional memory of EBOVAC1, as well as to trace post-trial career trajectories and explore capacities in human resources, research skills, and expertise built by the trial. Not only would this capture and preserve the institutional memory of EBOVAC1 before key members leave the project, but additionally serves as a baseline from which to trace post-trial career trajectories and the capacities in human resources, research skills, and expertise built by the trial.

Future Epidemic Preparedness and Community Surveillance

An important aspect of outbreak response preparedness for vaccination deployment is surveillance. Toward the end of the West African epidemic, community health workers and volunteers came to play a key role in early detection and timely reporting to the health system during the West African Ebola outbreak.  Given the infrastructural paucities in Sierra Leone’s health system exposed by the epidemic, interest in establishing community-based surveillance (CBS) mechanisms and improving contact tracing methods have gained momentum among the global health security community as an approach to address barriers to public health surveillance. Engaging community members to collect health information from within their communities and report it for public health surveillance purposes is increasingly gaining interest., and aA recently published output from a global technical meeting on Community Based Surveillance has sought to provide more clarity on a shared definition of CBS and establish guiding principles of best practice.

There is also increasing awareness that women, girls and other marginalised groups bear the heaviest burden of epidemics. Ebola and other recent epidemics such as COVID-19 have highlighted the urgent need for ‘gender responsive’ outbreak preparedness, response and recovery. The study will explore gendered ‘gaps’ in outbreak preparedness and develop recommendations for preparedness efforts through using both gender and health systems lenses.

Perceptions of Vaccination and Acceptance of Vaccination Strategies

We are conducting a study to explore about community level hesitancy towards such different vaccination approaches. Recent data emerging from the ongoing outbreak in the DRC demonstrates high acceptance of the Ebola vaccine, yet low acceptance of the ring vaccination and healthcare worker targeted strategies which are often characterised by perceptions of exclusion, political favouritism, and nepotism. This research is thus exploring vaccination strategies not as universally applicable policies, but within local contexts of implementation governed by institutional (mis)trust, memories of public health interventions, geopolitical landscapes, as well as trust in sources and methods of communication, to identify potential challenges and opportunities to different vaccination approaches. To identify the potential challenges and opportunities of various vaccination approaches, the research is exploring vaccination strategies not as universally applicable policies, but as situated within local contexts of implementation, governed by institutional (mis)trust, memories of public health interventions, geopolitical landscapes, as well as trust in sources and methods of communication

Following the outbreak of COVID-19 in March 2020, methods were adapted to ensure the safe conduct of continued research on community preparedness and response against the backdrop of an active epidemic. Research questions were also adapted to take into account recent deployments of COVID-19 and Ebola vaccines (deployed in view of a recent outbreak in Guinea), to consider how these experiences shape and are shaped by local perspectives on vaccination strategies.

Social network and contact pattern dynamics

How people interact, including patterns of social contact, shape the transmission of infections. The majority of social contact survey studies have been carried out in Europe among general populations and communities, with far fewer focusing on household contacts. In addition, much less is known about physical contact patterns in African settings.

How people interact at different stages affects how infections can be transmitted and it is also important however to understand what happens to contact patterns between people. A systematic review of social contact survey studies revealed that the vast majority of social contact survey studies have been conducted in Europe among general populations and communities, with much fewer focusing on household contacts.  Much less is known about physical contact patterns in African countries,

Anthropological approaches can aid mathematical modelling by helping to define the appropriate model and its structure. Participatory research can also be highly valuable in ensuring a meaningful interpretations of the model’s findings. This study aims to inform and improve estimations on the spread of infections by providing insights into contact patterns in West African settings. A fundamental way in which anthropological approaches can aid mathematical modelling is by helping to define the appropriate model and its structure. This could be the choice of modelling approach, model specification, and the domain of interest. Furthermore, participatory research can be highly valuable is the meaningful interpretation of the findings of the model.

A quantitative survey and geo-tracing methods are being piloted, alongside ethnographic observation and qualitative interview approaches, to test the practical application of these methods, which could be scaled to understand the complexities and differences in contact patterns within and between households. Data is being collected on movement and contact patterns among members of different age groups and genders in both rural (Kambia district) and urban (Freetown) settings.

ALERRT Social Science Work Package

Shelley Lees & Mark Marchant

ALERRT aims to reduce the public health and socio-economic impact of disease outbreaks in sub-Saharan Africa by building a sustainable clinical and laboratory research preparedness and response network.

Work package 5 is a social science led WP that aims to enhance and maintain the operational research capacity of the ALERRT network by developing and implementing a training and capacity development programme.

Crisis of Confidence

Luisa Enria

Project summary​

Challenges to scientific expertise are a growing concern across the world. Anti-vaccination movements and resurgent measles outbreaks in the United States and Europe have been linked to seismic political changes such as the rise of nationalist populism. Ebola outbreaks across Africa similarly highlighted the political undertones of resistance to epidemic control measures: rumours and anxieties reflected fragile trust in national authorities and external interventions. The COVID-19 pandemic has only made the political nature of outbreak response more visible across contexts, laying bare the impact of marginalisation on both disease dynamics and confidence in response measures and forcing reckonings in long-standing struggles for social justice. Epidemics become battlegrounds for these disputes, and these contestations create new opportunities for renegotiating the terms of political inclusion. How to engage meaningfully with mistrust and conflicts over different ways of seeing the world, then, is not simply a question for global health practitioners: it is a major test for contemporary democracies. If a ‘global crisis of expertise’ reveals deeper political tensions, we need to understand how this plays out in practice in order to address it. We must pay attention to everyday encounters with and contestations of scientific expertise as sites where trust is negotiated, political authority is challenged and alternatives to the status quo are articulated.

In recent years, efforts to directly address mistrust in epidemic response measures, for example during the 2014-16 West African Ebola outbreak, have sparked fruitful interdisciplinary collaborations and initiatives to open up the epidemic preparedness space to different voices, including social scientists and representatives from affected communities. However, these endeavours have also highlighted the difficulties of bringing together very different ways of knowing the world. In those spaces distinct ‘cultures of evidence’ become visible, as different standards, concepts and assumed hierarchies of knowledge confront each other. This can be seen in interactions between social scientists and epidemiologists involved in designing interventions, as much as in daily encounters between public health officials and traditional healers, or in citizens’ vaccination anxieties. Delineating the terms of engagement, across disciplines and between interventions and their target communities, is urgent but politically fraught.

In this fellowship, I take these two intersecting challenges, (mis)trust and the nature of dialogue between ‘cultures of evidence’, as my starting point. My aim is to explore the politics of negotiations over scientific evidence, taking the field of epidemic response and preparedness as a case study. I will interrogate the ecosystem of knowledge(s) that exist in this field, considering points of intersection at tension between disciplines and world views. I will take a multi-sited ethnographic approach, exploring connections and interactions across the different scales (global, national, local) and spaces that make up epidemic preparedness (from academic conferences and policy meetings to the ‘field’ where interventions are delivered and back), I will develop an analytical framework to identify the possibilities, limits and terms of ‘translation’ across epistemic communities and to uncover the politics and mechanisms of mistrust to develop innovative solutions for meaningful public engagement.

Objectives

  1. To build an interdisciplinary, adaptive analytical framework and to develop it through empirical research;
  2. To trial innovative solutions through collaborations with operational partners involved in the design and implementation of epidemic response and preparedness programming;
  3. To establish a research profile through training, mentorship and dialogue with different communities of practice

Research activities

In order to explore the everyday politics of encounter between cultures of evidence to build an analytical framework and practical contributions, the research will be led by three questions: i) What cultures of evidence exist in the space(s) of epidemic response and preparedness? ii) How are the assumptions and practices underlying these cultures of evidence enacted and contested in everyday encounters across different spaces? iii) What political relations, identities and imaginations become visible during these encounters? To answer these questions, research activities during my Fellowship will include:

  1. Training and Attendance at Meetings, Workshops and Conferences: To start defining ‘cultures of evidence’ I will take part in introductory trainings across different disciplines (e.g., infectious disease epidemiology) and practice-oriented learning packages and attend interdisciplinary workshops, meetings and conferences. These will be identified through mapping global networks of actors working in the field of epidemic preparedness and response. This will allow me to trace the ecosystem of knowledge in these spaces and observe interactions within and across disciplines and fields of practice.

    2. Interviews and Document Analysis: I will conduct interviews with researchers and practitioners involved in international outbreak response and preparedness efforts and do a discourse analysis of training materials and grey literature.

    3. Country Case Studies & Video-ethnography: I will develop country case studies to refine the analytical framework empirically. In the first phase of the Fellowship the case study will be Sierra Leone. This will include mapping out preparedness and response activities in country, interviews with national-level practitioner and participant observation in everyday encounters ranging from data collection for surveillance, vaccination drives, community engagement and outbreak response planning and implementation. This will be facilitated through a secondment to the Kambia District Health Management Team (DHMT) epidemiological surveillance office. I will complement this with ethnographic observation in community-led activities beyond formal preparedness interventions and a careful contextualisation of findings in political history and political economy analysis. During this ethnographic work, I will focus on a small number of individuals who act as ‘nodes’, or knowledge and trust brokers, and make a short film about their daily encounters as they navigate their work across different perspectives, mediating contestations, disagreements and mistrust. Further case studies will be defined over the course of the Fellowship.

    4. Operational Application: I will collaborate with operational partners to support their work in outbreak response and preparedness. This will allow me to test and refine the utility of my analytical framework for generating practical innovations in two areas. Firstly, in identifying avenues for meaningful communication and co-production of interventions across ‘cultures of evidence’. Secondly, in proposing new approaches to building trust, to foreground contextual programming that identifies trust as a political process of negotiating the legitimacy of an intervention.

Outputs

- Academic articles on key components of my analytical framework

- Policy and practice briefings and learning tools on an interactive online platform

- Bespoke support to operational partners

- A short film exploring everyday negotiations over scientific evidence and interventions in the field

- A dedicated website

- Co-production and public engagement workshops from the start of the fellowship

- Knowledge exchange and training materials for the Kambia District Health Management Team

Online and Offline Rumours

Hana Rohan, Luisa Enria, Anthony Mansaray, Shelley Lees, Mark Marchant

Since the COVID-19 pandemic began, there have been substantial concerns from the WHO and other operational agencies about the associated ‘infodemic’ (an excess of information, some accurate, and some not – that occurs during an epidemic), and its effects on perceptions, attitudes, and practices relating to COVID-19 prevention and response. Much of the risk communications and community engagement programming for COVID-19 has pivoted to an online focus, with new initiatives established specifically for this, and sizeable budgets committed to ‘debunking’ rumours and combatting online mis- and disinformation. However, it is not clear how valid rumours and dialogues on social media are as a reflection of real world (or ‘offline’) narratives or beliefs/practices, nor how much the two domains (e.g. social media and the offline domain) interact and influence one another, especially in settings with lower internet or smartphone penetration.

We intend to analyse Africa CDC’s continent-wide social media rumour tracking dataset, and conduct rumour ethnographies in two different settings (Kambia in Sierra Leone, and Coastal Regions in Tanzania), to better understand the relative influence and mechanisms of online and offline rumours regarding COVID-19 in two African settings.

Online and offline COVID-19 rumours in Sierra Leone and Tanzania

A thematic time series analysis of Africa CDC’s rumour tracking data will identify dominant rumours, allowing us to frame the context and content of ethnographic fieldwork around emergent and/or persistent online rumours. Rumour ethnographies will then explore contextual variations in how such rumours proliferate, levels of engagement with these narratives, and the relationship between online and offline narratives in these different settings.

This research will enable us to provide real-time recommendations for COVID responses currently underway in Sierra Leone and Tanzania (where possible), as well as for regional ‘infodemiology’ actors. It will also contribute to the academic study of infodemiology by integrating innovative and interdisciplinary methodologies (e.g. data science and ethnography). The project will also advance our understanding of the role of social media data in outbreaks, the appropriateness of using social media narratives to guide RCCE interventions, and their impact on offline community narratives around COVID-19.

Alongside producing publications for peer review, we will disseminate results to key global and regional risk communications and community engagement (RCCE) and infodemic agencies and networks, as well as to RCCE teams within local Ministries of Health and/or EOCs. We will also produce an ethnographic rumours toolkit, which will be publicly available through the Social Science in Humanitarian Action Platform and the RST knowledge hub. This builds on previous work due to be submitted for publication in May 2021 (reviewing qualitative tools for outbreak response) completed by the RST social science team, as well as on capacity building work that established the West African Social Science Epidemic Response Network. It also builds on existing LSHTM social science projects in Sierra Leone and Tanzania, further capacitating teams locally.

Rapid Anthropological Assessments of COVID-19 Impacts on Trust & Behaviours in Communities in the UK and Sierra Leone

Shelley Lees, Luisa Enria, Chrissy H Roberts

Co-Investigators:

  • Nina Rogers (MRC Epidemiology Unit, University of Cambridge)
  • Rosalind Eggo (LSHTM)
  • Hannah Brindle (LSHTM)
  • Naomi Waterlow (LSHTM)
  • Anthony Mansaray (LSHTM)
  • Joseph Macarthy (SLURC) United Kingdom

Led by Chrissy Roberts, Luisa Enria and Shelley Lees, this project has conducted a rapid social science assessment of the impact of COVID-19 (and associated control measures) on attitudes and behaviours towards the public health response in order to support effective and locally relevant communication and engagement strategies for the next phase of the COVID-19 pandemic. We did this through a mixed methods research platform that combines the power of web-based survey tools, statistical analysis, machine-learning text-mining and qualitative thematic coding. This has expanded on a first-round survey conducted in the United Kingdom in April 2020.

  • Roberts, C. H., Brindle, H., Rogers, N. T., Eggo, R. M., Enria, L., & Lees, S. (In press). Vaccine Confidence and Hesitancy at the start of COVID-19 vaccine deployment in the UK: An embedded mixed-methods study. doi:10.1101/2021.07.13.21260425

  • Enria, L., Waterlow, N., Rogers, N. T., Brindle, H., Lal, S., Eggo, R. M., Lees S, Roberts, C. H. (2021). Trust and transparency in times of crisis: Results from an online survey during the first wave (April 2020) of the COVID-19 epidemic in the UK.. PLoS One, 16(2), e0239247. doi:10.1371/journal.pone.0239247

  • Rogers, N. T., Waterlow, N., Brindle, H. E., Enria, L., Eggo, R. M., Lees, S., & Roberts, C. H. (2020). Behavioural change towards reduced intensity physical activity is disproportionately prevalent among adults with serious health issues or self-perception of high risk during the UK COVID-19 lockdown. Frontiers in Public Health

Sierra Leone​

Led by Luisa Enria and Joseph Macarthy this sub-study has conducted rapid social science assessments of the impact of COVID-19 (and associated control measures) on attitudes and behaviours towards the public health response in order to support effective and locally relevant communication and engagement strategies for the next phase of the COVID-19 pandemic, This has been done through a mixed methods research platform that combines the power of web-based survey tools, statistical analysis, machine-learning text-mining and qualitative thematic coding. We are also exploring the feasibility of adapting a survey instrument the research team developed for the UK survey for a Low & Middle Income Country (LMIC) setting; piloting the study in Sierra Leone, where our team members are currently conducting anthropological research. The survey has been piloted in two stages: a face-to-face survey and an online survey.

Violence against women

Shelley Lees, Sheila Harvey, Saidi Kapiga

Project Summary

A problem in itself, violence against women and girls is associated with HIV transmission as well as other aspects of global public health and development.  ​

A cluster randomized controlled trial (The Intervention with Microfinance for AIDS & Gender Equity – IMAGE Project) in rural South Africa combined a group-based microfinance intervention with a participatory gender and HIV training curriculum for loan participants and showed that, over a two-year period, levels of physical and/or sexual partner violence experienced by participants in the past year were reduced by 55%.

Maisha – which means “life” in KiSwahili – builds on the success of IMAGE and is seeking to:

  1. adapt, implement and evaluate the impact of the IMAGE intervention in Tanzania in reducing women’s past year exposure to intimate partner violence (IPV)
  2. find out if a participatory gender training curriculum delivered to women not receiving microfinance and to their male partners reduces women’s past year exposure IPV 

MAISHA comprises:

1. Two cluster randomized controlled trials:

  • Component A – 66 groups of women (average 20 women per group) who are already receiving microfinance will be recruited and randomised to either:
    • receive participatory gender training in addition to microfinance
      or
    • to continue receiving microfinance alone
  • Component B – 66 groups of women (average 20 women per group) who are not receiving microfinance, will be recruited and randomised to either:
    • receive participatory gender training along with their male partners
      or
    • to receive no intervention

2. A complimentary in-depth qualitative study to:

  • learn more about the factors that contribute to women’s vulnerability to violence
  • to better understand how the different intervention models impact on the lives of intervention participants and their families
  • how the different intervention models may reduce this risk

3. An integrated process evaluation to explore the implementation, receipt and context of the interventions.

4. An economic evaluation to evaluate the total costs of the development and implementation phases for each of the trials. A STRIVE project, the MAISHA study is a collaborative effort of:

  • the Mwanza Intervention Trials Units (MITU)
  • the Tanzanian National Institute for Medical Research (NIMR)
  • the London School of Hygiene and Tropical Medicine (LSHTM)
  • BRAC Tanzania

In Tanzania, the study is led by Dr Saidi Kapiga, Dr Gerry Mshana and Dr Sheila Harvey. In London, the study is led by Professor Charlotte Watts and Dr Shelley Lees.  

Publications

 

Training
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  • Applying Qualitative Methods in the Study of Vaccine Deployment - Anthrologica and LSHTM Report/Training Materials
  • Social Science Capacity Workshops / Capacity Strengthening Activity - Sierra Leone & Uganda
  • Qualitative Methods training and workshops / Capacity Strengthening Activity -  PREPVACC
  • Community Healthcare worker workshops (misinformation) / Capacity Strengthening Activity - Tanzania
  • NYU-WHO-UNICEF Behavioural Communication Strategies for Global Epidemics: Social Behaviour Change for Vaccinations - Guest Lecturer - NYU (2021)
  • Simple Guide to Coding/NVIVO - Training Materials