The Health in Humanitarian Crises Centre (HHCC) at the London School of Hygiene and Tropical Medicine (LSHTM) was founded with the aim of advancing health and health equity in crises-affected countries through research, education, and the translation of knowledge into policy and practice. The Fight Against Institutional Racism (FAIR) Network is a legacy of the 2020 Black Lives Matter protests and efforts by staff and students to address racism and coloniality within LSHTM. As an independent network, FAIR facilitates dialogue and action around racism and colonial legacies in global public health education, research and practice at LSHTM. FAIR worked collaboratively with HHCC on the mixed methods research underpinning this project.

The research team

The research team was formed of 3 FAIR members (Amber Clarke, Dr Katharina Richter, and Sali Hafez), the HHCC co-Directors (Dr Neha Singh and Dr Michelle Lokot) and Dr. Althea-Maria Rivas, an expert consultant who provided her expertise in critical, feminist and decolonial theoretical frameworks.

Study aim and objectives

This project aimed to create a charter and implementation guidance to enable HHCC members to embed decolonial practice into their work and to challenge the colonial history and legacies within research, teaching and partnerships. Specific objectives were to:

1. Identify characteristics of a decolonial environment (research, teaching and other practices) that can be embedded within the HHCC.
2. Explore current barriers and historical barriers/barriers over time, facilitators and good practices around decolonising research, teaching and other practices within the HHCC.
3. Explore current gaps, barriers and facilitators for decolonial partnerships with donors and other partners at the HHCC.

Methods

This project employed mixed methods research. First, the study team carried out a scoping review of current practical guidance on decolonising global/humanitarian health research, teaching and practice. Next, rapid qualitative research was conducted with internal HHCC and external actors to understand the barriers and facilitators to decolonising teaching, research and partnerships. In total, 20 semi-structured interviews were conducted: 10 internal HHCC member interviews and 10 interviews with external donors and research partners from local, national and international organisations. Focus group discussions were also conducted with 21 participants, namely with HHCC management/ leadership members (3 participants) and wider HHCC members (16 participants). Finally, internal HHCC members reviewed and discussed the findings and the draft Charter during design workshops and online consultation opportunities. The outcomes of all three research steps guided the development of the HHCC Charter and Implementation Guidance which are based on, and tailored to, the experiences and perspectives of HHCC members and external stakeholders.

Outputs

The outputs of this research project are two public-facing documents and two forthcoming academic peer-reviewed publications:

1. A Charter on Decolonising Our Work at HHCC which is to galvanise and steer collective action from HHCC members to decolonise research, teaching and wider Centre partnerships
2. An Implementation Guidance document which outlines how the Charter’s core principles and commitments can be implemented collectively, collaboratively and widely by HHCC members and leadership.
3. A peer-reviewed scoping review of practical guidance to decolonise the field of humanitarian health (expected to be published by Autumn 2023)
4. A peer-reviewed paper summarises the qualitative research findings (expected to be published by Autumn 2023)

Crises due to armed conflicts, natural disasters and food insecurity result in excess mortality and mental health problems, especially when people are forcibly displaced. Public health information plays a potentially key role in informing resource allocation and the design and implementation of humanitarian responses. Epidemics are a particular threat in crisis settings and create specific information requirements. The COVID-19 pandemic’s health impact in crisis-affected populations is mostly unclear due to inadequate testing and surveillance for SARS-CoV-2, stigma and other societal factors, and limited measurement of the indirect effects of control measures on various thematic areas, including sexual and reproductive health, non-communicable diseases and mental health, for which programmatic adaptations are warranted.

The pandemic has also highlighted the importance of retrospective and prospective monitoring of mortality (already a common information gap in humanitarian responses) as a key metric of ultimate downstream impacts, and a basis for fitting realistic transmission dynamic models. COVID-19 control has also relied heavily on non-pharmaceutical interventions, including hygiene behaviour change, a historically underfunded area with outstanding evidence gaps to fill.  Addressing the above evidence challenges must contend with a dearth of methodological expertise, shrinking humanitarian and researcher access to affected populations, and a post-colonial architecture that disempowers local actors. Against these challenges, we identify key capacity-strengthening and methodological innovation opportunities.

We have formed a consortium of academic and civil society organisations, funded by the US Centers for Disease Control, that proposes to work collaboratively and equitable to conduct research among crisis-affected and displaced populations in the context of COVID-19. This programme is a multi-disciplinary partnership, with LSHTM as the lead applicant, and partners in each of the research countries: the Université Catholique de Bukavu in DRC, SIMAD University in Somalia, the Bridge Network Organisation in South Sudan, and the Youth Peer Education Network (Y-Peer) in Sudan (who work under the umbrella of Adeela, a Sudanese civil society incubator NGO). Our partnership is committed to coproduction principles and will adopt a decolonial approach to research and humanitarian action. The LSHTM Principal Investigator is Francesco Checchi and LSHTM Research Manager is Lucy Bell.

This programme of research and capacity strengthening runs from February 2022 to September 2026, focused on four key crisis-affected countries (the Democratic Republic of Congo, Somalia, South Sudan and Sudan), but with flexibility to conduct data collection in new emergencies and other settings where existing collaborations facilitate this. This programme activities and studies are organised along three aims:

Aim 1: Establish or strengthen country-based, locally-led, multi-disciplinary humanitarian public health research units in the four key countries.

Aim 2: Explore novel cross-cutting methods based on community-led surveillance and data science methods.

Aim 3: Generate thematic evidence on the direct and indirect impacts of COVID-19 and other emergent public health threats, as per the following scientific objectives:

1. Generate improved all-cause and cause-specific mortality estimates.
2. Quantify transmission of SARS-CoV-2 and other epidemic infections.
3. Explore changes to hygiene behaviours, improve monitoring of hygiene behaviours and evaluate alternative behaviour change interventions.
4. Quantify and describe COVID-19’s secondary impacts on sexual and reproductive health.
5. Quantify COVID-19’s impacts on non-communicable disease burden and mental health and test novel care models.

Principal Investigator: Sian White (LSHTM)

Collaborators: Jean Lapegue (ACF), Melinda Foran (CAWST), Val Curtis and Karl Blanchet (LSHTM)

In stable settings, handwashing with soap is known to be one of the most cost-effective public health interventions, reducing diarrhoeal disease up to 48% and contributing to the reduction of undernutrition. When a humanitarian crisis occurs, whether it be a disease outbreak, a natural disaster or a protracted conflict, the social and physical environments of the affected population are disrupted. These disruptions result in behavioural shifts, including to behaviours of public health significance, such as handwashing with soap. There is a dearth of literature on hygiene behaviour and its determinants in emergencies. This is a significant issue for crisis-affected populations whose disease risk increases in the wake of an emergency. It is also an issue for emergency responders. While this evidence remains lacking it will impede the development of effective hygiene programs. The proposed research will map the determinants of hygiene behaviour and understand the constraints of hygiene programming within these crises settings. It will involve a multi-stage literature review, a policy analysis and a multi-country qualitative case study, with the aim of drawing recommendations for practitioners.

The objectives of this research will be:

• To develop a deep understanding of the determinants of hand hygiene in emergency settings so as to contribute to the development of rapid and effective behaviour change intervention tools.
• The field work for this research will take place in Kurdistan, Iraq and the Kivus, and the Democratic Republic of Congo (DRC). In Kurdistan, we will assess the determinants of behaviour among Internally Displaced Persons (IDPs) living in and outside camps during a protracted conflict. DRC is regularly affected by cholera outbreaks and will act as a case study of how people behave in a disease outbreak. We will assess the determinants of behaviour before and during a cholera outbreak.
• This research brings together the expertise of Action Contre la Faim (ACF), the London School of Hygiene and Tropical Medicine (LSHTM) and the Centre for Affordable Water and Sanitation Technology (CAWST). The study is funded by the US Office of Foreign Disaster Assistance (OFDA).