This summer I spent time in Dhaka, Bangladesh, working on the assessment of a mixed-age, group-based, caregiving-support intervention that integrates behavioral recommendations on water, sanitation, and hygiene, maternal and child nutrition, lead exposure prevention, child stimulation, and maternal mental health.
The quantitative endline data collection and analysis consumed the majority of the summer, where we closely monitored the data being collected on our tablet apps, communicated with our field enumerators and supervisors about any issues that arose, and adapted our strategies when required (for example, when, just in time, we realized that our data collection system was not set up to assess twins!). With the help of colleagues in Dhaka, we able to present preliminary results to the full study team before I left (just 2 weeks after the endline data collection finished!). Over the next few months I will be working with the data to assess the impact of the 9-month intervention on caregiving behaviors, maternal mental health, and child development.
A qualitative assessment which assessed the feasibility and acceptability of the behavioral recommendations, training of community health promotors, and the use of tablet technology was conducted alongside the quantitative endline. The focus groups, individual interviews, and observations have provided rich information to complement and contextualize the quantitative findings, and provide guidance as the team embarks in the next phase of the study which involves working towards scalability.
My time in Bangladesh was spent with a wonderfully smart and generous study team who have taught me about research and data collection in rural Bangladesh as well as Bangladeshi culture and hospitality. I will miss them! We are all very thankful to all our study participants and field staff, without whom this project would not have been possible. I am very grateful for the support provided by CGPH, and the opportunity that I was provided to further my studies of early child development in Bangladesh!
I’ve included a few photos below, if you’d like to take a look.
Clockwise from top left
1. The area surrounding one of the villages where the study took place
2. A view of Dhaka from above
3. A group session
4. A subset of the study team
PhD Candidate in Epidemiology
I first became interested in non-communicable diseases and their intersection with poverty when I was a CGPH fellow during my master’s. I spent 3 months in Rio de Janeiro studying diabetes and hypertension. I was very interested in why, with free and available medications, and an active community health worker system the majority of patients still didn’t have their diseases under control.
Now, as a health policy PhD student I am especially interested in non-communicable disease policy. This summer (actually, winter!) I spent several months in Santiago, Chile researching reasons for continued non-control of non-communicable diseases like hypertension and diabetes.
About three quarters of the Chilean population uses the public healthcare system, FONASA, funded primarily by a 7% tax on wages (for those above a certain income threshold. Not only does FONASA provide medications for non-communicable diseases totally free to its users, the system is also home to several innovative health policies: in 2016 the Nutritional Composition of Food and Food Advertising act was passed, requiring among other things the labelling of all processed foods that are high in sodium, sugars, saturated fats, and/or calories (per 100g), and restrictions on advertising these foods to children. See below for the labels on a jar of Nutella and a can of soda.
The Food Act was the government’s responses to rapidly worsening health statistics: Chileans have the highest per capita soft drink consumption in the world, and 60% of the population is overweight or obese. Whether they cause substitution away from these foods is yet to be seen – as far as I know several academics in addition to the ministry of health are currently evaluating the policy.
A second innovative health policy – and one I worked on evaluating this summer while in Santiago – is the PSCV appointment reminder program. This program, which was phased in to primary care clinics over the past three years, signs up patients with non-communicable diseases for text message reminders. Patients receive a reminder before their scheduled appointment. They can respond to confirm the appointment, or reply that they wish to reschedule. The text message also serves as a reminder to take their medications. Not only does this text message serve as a nudge to keep NCD patients in care, it also allows the primary care center to reallocate appointment slots if the patient texts back that they wish to reschedule the appointment. Our hypothesis is that this program will not only improve health, but cause positive spillovers to patients not directly enrolled in the program who are now able to get same-day primary care appointments.
My summer (winter) spent in Santiago working in collaboration with researchers at the Universidad Catolia de Chile was an enriching experience, and left me with more questions than I began – good news for a graduate student! I will be continuing to work with the mentors and peers I met this summer, and am grateful for the continued support from the Center for Global Public Health.
Traveling almost half way across the globe to conduct my internship in Vietnam this summer has been an incredible journey. Thanks to support from the CGPH, I have had a chance to revisit my homeland to work with the Wildlife Conservation Society Vietnam on the Emerging Pandemics Threat Program initiated by USAID through a project called PREDICT-2. In the second phase of now a 9-year long project, WCS continues collaborating closely with the government and local partners to conduct biological and behavioral surveillance for better understanding of the risk of spillover of viruses of potential public health significance at the human-wildlife interface. The interdisciplinary approach of the project has introduced me to new regions throughout the country and a network of researchers and local communities working together to prevent zoonotic diseases in humans and animals.
Our office is located in the capital Hanoi in the North of Vietnam. I spent about one third of my time here in the office, and for the rest I went on field trips collecting samples, assisting with qualitative research, and ran diagnostic tests in PREDICT partner laboratory at the National Institute of Hygiene and Epidemiology (NIHE). My very first sampling trip was done at various locations in Dong Thap Province that stretches along the Mekong delta in southern Vietnam. Near the receiving end of the generous river system is a plethora of tropical fruits, vegetables, and endless green rice fields in the summer intertwined with a number of wildlife farms and live animal markets. Amid local markets selling a variety of terrestrial and aquatic animals and meat, at one point our team, which was led by local authorities, looked for the stands of field rats or “chuột đồng”. This taxa (rodents), which is one of the three primary taxa of our focus besides bats and non-human primates, is considered a specialty by the local people and has such a high demand that they are sometimes imported from neighboring countries, like Cambodia, for consumption. Cages carrying rats can be spotted from a near distance around the meat market, or people can find them at other private vendors in this region. Another interesting field site I visited was at two bat guano farms. These are artificial structure built with high stalls covered by coconut leaves to attract bats on top and gather their excrement on the basement for fertilizer. While the risk of disease spillover is still to be elucidated at this human-wildlife interface, these various field sites are an integral part of the local people’s daily life, illustrating various ways of interactions, directly or indirectly, between humans and wild animals, and apparently they represent an important node in the One Health triad interconnecting also with human and environmental health.
The mission of the surveillance project is not only trying to protect human health by proactively detecting virus at its source, but also implementing wildlife protection strategies for endangered species. I was also fortunate to be able to participate, during my second field trip, in a health check for pangolins with Save Vietnam's Wildlife team in Cuc Phuong National Park. These pangolins were confiscated by the authorities from wildlife trafficking network and were undergoing health check before they were released back to their natural habitats in July. Working with this critical species was a rare opportunity, and I have been extremely grateful to be on the sites with dedicated team of veterinarians and staff working at the intersection of human and animal health to protect the health for all. Besides tremendous support from the CGPH, I would like to thank Dr. Peter Dailey for guidance with the project proposal and Dr. Amanda Fine as well as WCS Vietnam staff for welcoming me to the team and making these experiences possible.
Photo credit: WCS Vietnam Health Team
For the past few months, I have been conducting research on the prevalence of community-acquired urinary tract infection and current trends of E. coli antimicrobial resistance within the Burj al-Barajneh region of Beirut. Our team, comprised of individuals from both UC Berkeley and the American University of Science and Technology, represents a diverse background of expertise. The faculty here has been more than welcoming, and is excited about working with Dr. Lee Riley on this and future projects concerning slum health realities and potential solutions among the refugee communities here in Lebanon. This is the very first time AUST has been involved in a project with an international exchange student from the United States.
Our team has made significant progress since beginning in mid-May. Despite many challenges, we have persevered, and are well on our way to collecting all the required surveys and urine samples to complete our work. One of the most challenging aspects is the high rate of antibiotic self-medication, which not only accelerates the development of hazardous antimicrobial resistance, but also reduces the number of individuals who seek conventional healthcare from clinics and hospitals where we are recruiting participants. The lack of governmental oversight allows for illegal sales of medication without a doctor’s prescription, with many individuals opting to bypass physician visits entirely. Burj al-Barajneh is plagued with slum conditions due to the massive influx of Syrian refugees since the beginning of the Syrian conflict, leading to crowdedness, inadequate sanitation, and systemic poverty. This has led to an interesting population composition, as Burj al-Barajneh is inhabited by all three populations: Syrian refugees, Palestinian refugees, and Lebanese natives.
This project has truly laid the groundwork for future academic collaboration between UC Berkeley and the universities here in the Middle East. We have established relationships with key stakeholders in the region who are invested in the health and wellbeing of Syrian and Palestinian refugees, first and foremost of which is Amel Association. Amel Association works with victims of crises residing in Lebanon, and offers healthcare, psychological care, and vocational development for its patrons. I look forward to continuing the work we have begun here in Lebanon, both for the duration of the summer and in the future.
Photo: Agatha (research assistant), Dr. Omobola Mudasiru (UC Berkeley post-doctoral fellow), and myself en route to conduct a survey at a participant's home
It’s hard to believe I’ve already been in Shinyanga for two months! This summer has been a wonderful opportunity to expand my professional/leadership skills and to gain experience working in a resource-limited setting.
I’ve really enjoyed living and working in Shinyanga. The people are so warm, but it is clear that significant barriers prevent people in Shinyanga from receiving medical care, and in particular, HIV care. A huge stigma still surrounds HIV, and this stigma deters people from getting tested, sharing their status with their partners, or seeking HIV care. Additionally, we are conducting our study at a large regional hospital, and many people avoid the hospital because it is rumored to be a death sentence. Even if people can find the money, transport, and time to receive HIV care at the hospital, they spend an entire day with 300 others waiting to see a provider. These are just a few of the barriers people in Shinyanga face, and the surveys we’ve been conducting have highlighted many more.
Since I'm not working on primary data collection (due to language limitations) but rather focusing on management and data analysis, it's tempting to occasionally disconnect from what I'm studying and feel like I have a regular office job. However, I'll be working on the survey and code a question about whether you can't make it to the clinic because your partner hasn't given you permission or if you ate less food this month because you didn't have enough money or if you've been beaten by your partner recently. In this moment I am instantly reminded of where I am and what I'm doing. On top of that, our office is located within the Regional Hospital, and every couple of days I hear heartbreaking screaming from family members who are devastated when a loved one dies. It can be a lot, but I’m so thankful to have worked in Shinyanga this summer and to now better understand these barriers to HIV care.
Shirati is a small village in the northern part of Tanzania. Approximately 15 miles from the Kenyan border, the closest airport is a 6-hour drive. The roads are unpaved and washed away in many places by rainfall. Cows and goats are more commonly found trotting along the roads than are cars and motorcycles. To say that Shirati is rural would be a gross underestimation. Shirati's distance from major cities and towns elsewhere in Tanzania presents its residents with unique challenges, including access to clean water, sanitation services, and other resources. The majority of the population is estimated to live on approximately $1 per day. Diseases, including schistosomiasis and malaria, afflict large proportions of the population.
Yet, despite these challenges, the people of Shirati are the kindest I have ever had the pleasure of knowing. The majority of my project involves entering the community to conduct surveys on water quality and diarrheal disease. Every day, I visit new strangers' homes and am always welcomed with a warm "Karibu sana." Chairs are brought out for the strange muzungo visitor, and nearly every home, despite intense poverty and lack of food sources to feed their large families, offers maize or beans. Children, in particular, are strong and resilient. Their loving spirits and eagerness to play with muzungo visitors despite the challenges they face daily is truly inspiring and heart-warming.
Thus far, my project has been incredibly enlightening.I have sampled 6 different water sources and surveyed numerous families. Despite an incomplete data set, it is already abundantly clear that diarrheal disease impacts a large percentage of the population in Shirati. Those that rely on Lake Victoria appear to be particularly vulnerable. The rest of my time here will continue to illuminate the immense disease prevalence the Shirati community faces. I look forward to continuing this research and working closely with the wonderful people who I learn from each and every day.
After 2 days of flying and a one and half hour car ride, I made it to Kampala, Uganda, where I’ll be spending the next few months doing Tuberculosis (TB) research. My colleague from UCSF has been showing me around for the past couple days getting set up with a phone, acquainting me with the area, and finalizing all the project materials, so now I feel ready to take on the summer! I’ll be writing many of the SOPs for the first part of a TB treatment implementation trial and going to hospital sites to enroll them in our study. On June 5, I’ll be going with another TB team to enroll health centers in preparation to do that myself in July. The people I’ve met at the project offices have been very welcoming and coincidentally my roommate was also a former UC Berkeley MPH IDV graduate now doing her PhD at Hopkins. (Go Bears!)
When I first started my MPH in the fall of 2017, I knew I wanted to do international TB work for my internship and I am very appreciative of the funding and support CGPH has provided to make this journey possible. I’ve done molecular TB research in the years prior to graduate school and am excited to work on studies that now focus on the public health epidemiology of the disease. Can’t wait to get immersed in the work, explore an amazing country, and get my project done this summer!
MPH IDV, 2019
This summer, I will be working with a team at the International Centre for Diarrhoeal Diarrheal Disease Research, Bangladesh (icddr,b) to evaluate a group-based integrated caregiving support program in Kishoreganj, Bangladesh. The intervention integrates behavioral recommendations for water, sanitation, hygiene, nutrition, lead and arsenic exposure prevention, and early child stimulation, and aims to change caregivers’ behaviors, and improve child health and development.
Over the next month I will assist the team with the development and refinement of our endline survey, which will take place over 3-4 weeks in June and July. In advance of data collection I will also be working with the team to create a pre-analysis plan. I am looking forward to working with a supportive and dedicated team of researchers at icddr,b in Bangladesh this summer, and am very thankful for the opportunity provided by the CGPH summer fellowship!
PhD Candidate in Epidemiology
I am very excited to have the opportunity to work in Shinyanga, Tanzania this summer thanks to the support of CGPH! I will assist with a follow-up study that is examining the effects of food and cash transfers on antiretroviral adherence of food-insecure adults living with HIV.
I began working remotely on this study in September 2017, and I’m thrilled to have the opportunity to witness it in person and help it progress to the next step. I’ve seen the project move through many phases--from initial conceptualization, to protocol development, to data collection, and now data analysis. I believe that this past year of preparation will set me up for a successful summer! In addition to my role as a research assistant, I have prepared by taking Swahili lessons and by forming virtual relationships with the local team. I am very excited to continue developing these relationships, to expand my leadership role, and to grow my analysis skills as an Epidemiologist.
Epidemiology & Biostatistics MPH Student
Today I am boarding a flight to Beirut, Lebanon, once hailed by the world as the “Paris of the East” for its booming tourism industry, now better known for the one million Syrian and Palestinian refugees it shelters and grants asylum. Today marks the beginning of a three-month project seeking to illustrate local trends of uropathogenic E. coli antimicrobial resistance present among Syrian refugees, Palestinian refugees, and Lebanese natives living in Burj al-Barajneh refugee neighborhood. Compiling these profiles of resistance will hopefully assist local healthcare officials in guiding treatment regimens of UTI patients to avoid exacerbating resistance, in addition to shedding light on the genotypes associated with resistance amongst E. coli strains in the Middle East. This information represents a critical addition to combatting the growing prevalence of antibiotic resistance in the region.
To prepare myself for this project I am listening exclusively to Arabic podcasts and news reports in the Lebanese dialect to immerse myself fully in the language. Polishing my Arabic language ability will be crucial for engaging with refugees in a culturally-sensitive and appropriate manner. I am thrilled to have the opportunity to work in Lebanon alongside a local university in central Beirut, the American University of Science and Technology, which houses some of the leading minds in investigating communicable disease among local refugee populations. I know that this experience will educate me beyond any expectation, and will challenge me both intellectually and emotionally.
MPH Student in Infectious Diseases and Vaccinology