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Potential research project topics

Theme I: Transdisciplinary approaches to the elimination/control of infectious diseases of poverty

Project 1: The development of HIV drug resistance and the identification of its determinants at the level of patient, health care provider and health system with particular emphasis on social and behavioral aspects (Host Institute: AMC)
As access to antiretroviral treatment (ART) in resource-limited settings is continuously expanding, evaluation of long-term outcomes, including trends in the emergence of HIV drug resistance are important to inform ART policy. Since 2007 the PharmAccess African Studies to Evaluate Resistance (PASER) monitor and evaluate clinical, immunological and virological outcomes of ART programs in relation to the rate of HIV drug resistance in sub-Saharan Africa. Identification of determinants of therapy failure at the level of the patient, health care provider and health system is considered of value to improve quality of care and sustain national ART programs.This project is designed as a transdisciplinary (biomedical and socio-anthropological) approach to evaluate the performance of various ART programs in different African settings. The research is particularly meant to provide insights into the various factors that are facilitating poor treatment outcomes, including HIV drug resistance and therefore represent potential threats to the success of global HIV control. Original PASER clinical and biomedical approaches will be complemented with sociological and behavioral studies. Findings are expected to be taken up by various stakeholders and to further contribute to African ART policy, both at the national and international level.

Project 2: Transmission of malaria parasites (Host Institute: CRESIB)
Malaria disease is produced by repeated cycles of asexual growth of Plasmodium spp. parasites inside of human erythrocytes. At each cycle of asexual growth, a small proportion of the parasites convert into male or female sexual gametocytes that develop for several days until they are competent for growth in an Anopheles mosquito. Sexual conversion is a fascinating biological process, but also a major public health concern as only sexual forms allow transmission from one human to another via a mosquito vector. There is ample consensus in the scientific community that any intervention aimed at eliminating malaria needs not only to cure disease but also to target sexual stages, which do not produce disease but still transmit malaria to other humans. We have recently identified the key transcription factor (TF) that triggers sexual conversion in Plasmodium falciparum. In this project, we will combine laboratory-based, epidemiological and medical anthropology research to: (i) investigate the expression dynamics of this TF under different clinical conditions and establish its usefulness as a key component of a molecular test aimed at characterizing the human malaria infectious reservoir; (ii) investigate the social perception of testing and potentially treating healthy infectious individuals.

Project 3: Challenges in eliminating Neglected Tropical Diseases: Visceral Leishmaniasis  in Nepal as a model (Host Institute: ITM) 
Elimination initiatives for Neglected Tropical Diseases face similar challenges. In 2005 India, Nepal and Bangladesh launched a joint visceral leishmaniasis (VL) elimination initiative to bring the incidence down to less than 1 case per 10,000 by 2015. Less than two years away from the deadline the number of cases is still rather high in those countries, with Nepal being closest to the elimination target. However, data are weak and ascertainment of elimination not well defined. The experience gained in the last decade in the Indian subcontinent indicates that new strategies and criteria should be adopted to properly evaluate control efforts and ascertain the elimination of VL in a given region. This project will exploit innovative epidemiological, immunological and entomological tools to evaluate the impact of current and past control measures against VL in Nepal. It will also explore how to increase awareness of VL at community level with regards to early recognition and referral for diagnosis and treatment. These new tools will be useful for other VL endemic areas in India and Bangladesh and may translate to other Neglected Tropical Diseases.

Project 4: Patients’ perspectives and health care seeking behaviour regarding tuberculosis in selected African countries. A proposal for a comparative anthropological and sociological health research (Host Institute: AMC)
Tuberculosis (TB) remains a disease with enormous public health impact, especially in resource-poor settings. TB diagnosis and treatment are cumbersome, and socio-cultural factors add to the complexity of managing the disease. Insight into these factors is of utmost importance in order to facilitate the improvement of TB care. Therefore, we aim at assessing illness perceptions of TB and determining influential factors on health care seeking behaviour of TB patients and healthcare provision in three African countries: Gabon, South Africa and Mozambique. Selection of countries is based on the high TB (and TB-HIV co-infection) prevalence and the usage of different health care programs and health outcomes. This innovative, comparative research will be conducted using a unique combination of quantitative and qualitative methods. Triangulation is guaranteed through the usage of surveys, in-depth interviews, focus group discussions, and participant observation. A critical medical anthropological framework is used, departing from a multilevel perspective. This allows for analysis of patient- and community related factors (local level), but also of healthcare providers (institutional level) and of the national healthcare system (national level). Data will be published in peer-reviewed journals and are expected to inform tailored approaches to TB care in the local setting and beyond.

Project 5: Malaria at the pre-elimination era: New challenges for politics in West Africa and Indian Ocean countries (Host Institute: Bordeaux)
Reaching the pre-elimination epidemiological threshold is an important milestone in disease control. Concerning malaria, it is now a realistic objective for many countries where the epidemic activity is low. Paradoxically, this situation carries some risks of morbidi-mortality, as individual premunition decreases while the vector persists. This imposes reconsidering the country disease management organisation, and shifting from a disease-control to a pre-elimination paradigm. For this, developing innovative health politics, economics, and social priorities options is needed. Actually, failing in this could lead to local recrudescence of the epidemic. We aim at studying the issues in setting-up new health systems and politics goals, organisation patterns, and epidemiological surveillance tools when shifting from malaria control to pre-elimination goal. By identifying the determinants of this major reorganisation, this research final objective is to help the concerned countries successfully achieving this transition by identifying the impediments or advantages related to their particular setting. The achievement of this transdisciplinary goal requires the collaboration of researchers in politics, epidemiology, medicine, and sociology, and exchanging with the different stakeholders of malaria management. To accomplish it, case studies will be conducted in Senegal and Madagascar. They will focus on fieldwork integrating historical and political perspectives through multilevel approach.

Project 6: One Health approach to monitor the risk of anti-leishmanial drug resistance in Europe (Host Institute: CRESIB)
Leishmaniasis, a zoonosis affecting dogs and people in the Mediterranean area, and antimicrobial resistance are two important public health concerns in Europe. The limited number of effective and safe anti-leishmanial drugs requires the implementation of surveillance mechanisms to ensure the appropriate use of these drugs to limit the risk of developing and transferring resistant Leishmania infantum strains. We propose to develop a surveillance system in an endemic area for leishmaniasis in Europe, to 1) monitor the use of anti-leishmanial drugs in humans and dogs and 2) evaluate the risk of emergence of resistant parasites. Only by taking a One Health approach and thus integrating physicians, veterinarians, epidemiologists and molecular biologists into one surveillance system, evidence-based recommendations on the use of anti-leishmanial drugs to treat both humans and dogs in Europe can be developed. If this study proves successful, our surveillance system could be replicated in other leishmaniasis endemic areas or for other zoonotic diseases.

Project 7: Elimination of new HIV infections among children in poor populations: Clinical and immunological insights and evaluation of preventing strategies (Host Institute: CRESIB)
The ambitious goal for eliminating pediatric HIV infection worldwide has been prioritized by the United Nations Programme Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, and builds upon the global efforts and progress in the scale-up of prevention of mother-to child transmission of HIV (PMTCT) and antiretroviral (ART) coverage. Most of the mechanisms of HIV MTCT are still unknown and the reasons why some mothers transmit the infection to their infants whilst the majority does not is not well understood. Current knowledge gaps in this subject might have hindered the success of existing preventing strategies to control HIV in pregnancy globally. This research project will contribute 1) to understand the underlying mechanisms and the factors involved in the exposure of the foetus/child to HIV in pregnancy assessing their potential role on HIV transmission, 2) to investigate risk factors for morbidity and mortality of HIV exposed children and, 3) to evaluate current preventing strategies for MTCT from a holistic perspective, addressing context specific social, cultural and economical determinants and to identify key barriers that limit their effectiveness. Existing preventing measures have failed to overcome the global inequity between the countries in which infants are rarely infected with HIV and those in which this is still common. This project has also the ultimate goal of using this information to evaluate existing preventing strategies and translate it into a comprehensive, integrated and sustainable approach for the prevention of HIV in pregnancy and MTCT.

Project 8: Determining the Contribution of Different Types of Human Mobility to Malaria Transmission Dynamics in a Malaria Elimination Context: a Comparative Transdisciplinary Study (Host Institute: ITM)
Characterizing malaria transmission dynamics requires an in-depth understanding of human behavioral factors such as human mobility patterns (migration, mobility, social networks) and territorial arrangements (housing/settlement systems such as temporary shelters) in relation to malaria infection. As such, accounting for human mobility is a key aspect of malaria control, elimination and post-elimination, as evidenced by previous elimination attempts that were undermined by the reintroduction of malaria through human population movements. A comparative transdisciplinary study design combining social science and biomedical research will be carried out in Vietnam, Peru and The Gambia. The social science study will consist of a mixed-methods study design, triangulating qualitative ethnographic data and quantitative survey data gathered using a malariometric survey. The biomedical study will combine epidemiological parameters of malaria infection and disease with genotyping methods aiming at evaluating the parasite population at the individual and (sub-)population level and the migration of existing clones.

Theme II: Shifts to non-communicable diseases (NCDs) and the interaction with infectious diseases

Project 9: Innovative interventions for chronic diseases in less-affluent urban societies (Host Institute: VU)
The urban poor are challenged by their harsh physical and social environment and they often have to deal with a plethora of health issues. These range from infectious diseases such as tuberculosis to newly emerging chronic conditions such as cardiovascular diseases and diabetes. Changing lifestyle behaviors (eat more fruits and vegetables, stop smoking and stop the harmful use of alcohol, become physically active) to decrease these chronic conditions is one of the cornerstones for intervention, however very difficult to achieve. In addition, how can these health conditions be improved in such challenging environments? One interesting and novel approach for these areas, is the use of nudges. A nudge is a simple, cheap, intervention that alters people’s behavior with a gentle ‘push’ in the healthy direction. This research therefore aims to develop interventions using nudging to encourage people to live a healthy life and specifically addresses people that are double burdened by chronic and infectious diseases. The research uses the Interactive Learning and Action (ILA) approach and the research methods (quantitative and qualitative) include participation of patients, community members, health professionals and other stakeholders.

Project 10: Do parasitic infections fuel the rise in (established predictors of) non communicable disease outcomes in low and middle income countries? (Host Institute: ITM)
An increasing number of low and middle income countries (LMICs) face a substantial shift in burden of disease. While many nations still struggle to reduce infectious disease burdens, non- communicable diseases (NCDs) such as diabetes and cardiovascular diseases are emerging in epidemic proportions. It is well-known that overweight/obesity poses a major risk for these NCD outcomes, and so do early child stunting and low infant birth weight. However, policies to address these risk factors are mainly developed from a nutritional perspective only, often with detrimental results. For example, food policies to address child under nutrition have been shown to exacerbate adult obesity, contributing further to chronic disease risks. The role of parasitic infections in NCDs has so far been understudied. Nevertheless, parasitic infections are very common in LMICs, and are well established as a cause of child stunting. Additionally, they have been linked to LBW and overweight/obesity. Hence, targeting parasitic infections may be a novel strategy to combat NCDs by simultaneously addressing a range of NCD risk factors. This study aims to elucidate the role of parasitic infection in relation to (established predictors of) NCDs in LMIC countries. A transdisciplinary collaborative approach will be used, involving the input of key stakeholders from health organizations and disease control programs, while integrating knowledge from field epidemiology, parasitology, and nutritional science.

Project 11: Addressing the double burden of non-communicable and communicable diseases in Vietnam (Host Institute: VU)
The rise of non-communicable diseases (NCDs) and continued high prevalence of communicable diseases poses a double threat to health systems in low and middle-income countries (LMICs) which face substantial resource constraints and fragmentation in finances and services. Services, health professionals and finance allocation in many health systems in LMICs are fragmented, and integration of services and pooling of financial mechanisms has been suggested as  way to reduce fragmentation and improve overall health system performance. There has been limited evidence on integration strategies, particularly in LMICs, thus this study aims to use Vietnam as a case study to explore approaches to integrating care for communicable and NCDs, specifically focusing on differences between urban and rural contexts and on vulnerable populations (e.g. those afflicted with poverty, persons with disabilities). This study uses a transdisciplinary research approach to explore existing service approaches to preventing and managing communicable and NCDs, understand help-seeking strategies of vulnerable populations who face this double burden of disease, and pilot a strategy for an integrated care solution in Vietnam. This project will synthesise inputs from medicine, systems thinking, epidemiology and public health. Lessons learned from Vietnam can be shared with other low LMICs facing similar constraints and fragmentation in services.

 Theme III: Innovative approaches to enhance access to health care and prevention

Project 12: Realizing universal health coverage through the inclusion of marginalized groups (Host Institute: VU)
Persons with disabilities are often (unintentionally) excluded from development programs and social interventions. Yet, they eminently require equal chances to participate, not in the last place to break the vicious cycle of poverty and disability. In this PhD-project, an Interactive Learning and Action- approach is applied in  community settings in East-Africa, to create and evaluate context-fit interventions that are aimed at improving the access to quality public health for persons with disabilities. At the same time, we intend to reach out to the non-disabled community as well, as we believe that the process of mainstreaming disability in public health will ultimately benefit the general public.

Project 13: Improving access to health of rural women through mHealth (Host Institute: VU)
The use of mobile devices for improved information management and communication in healthcare and public health (mHealth) in developing countries is expanding quickly, including in the field of Sexual and Reproductive Health (SRH). However, many mHealth projects are still in an experimental phase and systematic evaluation has only recently started. There is still very limited evidence on the possibilities of effectively using mobile phones among beneficiaries, in particularly women, in rural contexts. Moreover, it is not clear under which conditions and how mHealth can make a difference compared to other “traditional” communication and information strategies. The aim of this research project is to assess the effectiveness of the use of mobile technology to 1) improve access to sexual and reproductive health services, particularly of rural women and to 2) obtain insights in facilitating and constraining factors (including technological, social, economic, cultural and ethical factors) for the successful implementation of these applications. The research methodology will include a realist review on the current evidence of the effectiveness of the use of mobile technology for improving access to health services for rural women. Secondly, the project will use a multiple case study approach to assess effectiveness in practice. For the case studies, the PhD student will collaborate closely with NGOs that are implementing an mHealth project in India, Ghana and/or Kenya.

Project 14: Reconceptualising HIV testing in the era of “test and treat”: Novel approaches to intensifying HIV testing (Host Institute: CRESIB)
In spite of the progress made towards universal access to HIV treatment, the uptake of Voluntary Counselling and Testing (VCT) has remained low both in areas with generalised epidemics and in high-income countries with epidemics concentrated in groups facing overlapping vulnerabilities, including ethnic and sexual minorities. Beyond the provision of conventional client-initiated VCT services, a move towards innovative intensified testing modalities such as self-testing, mass HIV mobile testing, provider-initiated testing, couple testing, as well as home and work-based testing will be required if universal access to treatment is to be achieved. Drawing from different stakeholders’ perceptions, this study will inform the translation of global HIV testing guidance into locally feasible and successful interventions. The project will address gaps in the understanding of 1) Underlying mechanisms and pathways guiding individuals’ testing decisions, 2) Perceived pros and cons of different dimensions of various testing modalities including VCT, home-based, self-testing and provider-initiated testing, 3) Determinants of sustained optimal adherence to antiretroviral regimes in contexts of overlapping vulnerabilities and earlier start of therapy 4) Changes in risk perceptions and disclosure decisions triggered by early HIV treatment initiation. It will also inform the development of training materials, guidelines, and the tools required to assess the operational implementation of intensified testing programs, so interventions can be tailored to patient and providers needs and corrective measures adopted in a timely manner.

Project 15Evidence to support progress towards Universal Health Coverage: need for comprehensive monitoring and evaluation frameworks (Host Institute: ITM)
Universal Health Coverage (UHC) is prominent on the development agenda. The goal of UHC is to ensure that all people obtain the health services they need without suffering financial hardship. However, measuring the progress towards this goal is all but easy. To date, the mainstream WHO analytical framework that is used to evaluate UHC strategies fails to capture the whole complexity of the UHC strategy. This call proposes to develop and test, in a variety of contexts, in low- and middle-income countries, innovative methodological approaches that enable unravelling the complex processes that facilitate/undermine the UHC progress. Adding effective tools to measure UHC to the toolkit of health equity intervention research is consistent with the recommendation of the World Health Organization’s Commission on Social Determinants of Health “to measure and understand the problem and assess the impact of action”. Particular attention will be given to the Non-Take-Up (NTU) of entitlement, to understanding how this phenomenon occurs, especially when it is driven by social exclusionary processes. This will provide highly informative insights on the causes that explain why significant proportions of populations in LMIC are excluded from accessing quality health care when the need for it arises. The need for multidisciplinary research is obvious. The eventual potential societal impact is huge: providing knowledge and insight to policymakers in their endeavour to design and implement more equitable systems of social health protection and to significantly advance on the road to UHC.