Indigenous knowledge and Intersectionality: “Incremental radicalism” and Frontline Health Workers


Health Systems Global 2016 was opened by leaders of the Canadian First Nation community through song and dance and a discussion of how health has four components: physical, mental, emotional, and spiritual. The First Nations Perspective on Health and Wellness stress the need for a balance between these aspects of wellness and that they are all nurtured together to create a holistic level of well-being. 

It struck me that this conceptualisation, together with intersectionality, is a good way to think creatively about ways forward in health systems, and in particular the experiences of frontline health workers.

Physical health: In the conference opening plenary Karsor Kollie, head of the Liberian NTD programme, discussed the impact of Ebola on front line health workers: death, injury and morbidity. Later in the conference video extracts of him interviewing community based drug distributors demonstrated the risks they faced as their roles expanded to include community action on Ebola and the burial of the deceased. Zara Trafford from University of Cape Town, also brought video insights from community health workers (CHW) in South Africa. One exhausted female CHW had an accidental needle stick injury; unlike formal paid cadres, such as nurses, she was not entitled to post exposure prophylaxis. This led to physical risk of infection, extreme stress, and a strong sense of being undervalued. The physical health impacts on front line health workers on CHWs working in contexts affected by conflict and epidemics is acute. Clearly CHWs deserve the same levels of protection as health workers in other cadres.

Mental Health: Work on promoting a resilient health workforce in conflict affected areas highlighted the many mental health impacts on front-line health workers including post-traumatic stress disorder, insecurity and fear, and the risk and reality of abduction. Haja Wurie from ReBUILD explained how health workers were a specific target for abductions during the northern Ugandan conflict, and had to disguise themselves in order to get to work. A skills building session on life histories, used participatory approaches to understand health workers’ experiences during and post-conflict to explore how individual experiences are shaped by broader contextual changes with many mental health implications stemming from violence, trauma and fear. Close-to-community providers deal with a wide range of issues with implications for their own mental health: domestic and sexual and gender based violence, abuse, alcoholism. Polly Walker, explained how World Vision incorporated Psychological First Aid training in their core CHW model in response to increasing need. Observation of implementation in over ten countries shows immense need here on the importance of skills-building for both mental health and psychosocial support of CHWs working in a wide range of circumstances not only to serve their client better, but also to better cope with their own experiences. World Vision are currently working on a more in-depth model for support.

Emotional Health: Despite the multiple challenges for mental and physical health, front line health workers, demonstrate “reservoirs of resilience”. New technologies can also play a role here: in Sierra Leone, in the face of Ebola, health workers used WhatsApp groups to support each other, and share vital safety information. Sophie Witter shared how coping strategies for conflict were gendered and shaped by poverty and household structure. Families, sense of nationhood and patriotism were all strategies deployed by health workers to build emotional health in these contexts. REACHOUT research within complex adaptive systems brought insights by highlighting the importance of the software of health systems (relationships, reciprocity, and trust) alongside the hardware (training, supervision and policy). When strong, respectful and trusting relationships are in place for CHWs – both with supervisors and communities – emotional health is likely to be enhanced. 

Spiritual Health: The First nations community explained that “Nurturing spirit is the aspect in your life that makes you smile! This is about what makes you feel good and connected. This builds your self-esteem, self-confidence and allows you to be connected to others, mother nature and yourself.” With strong links to emotional health and social capital, religious faith can help build the spiritual health of frontline health workers. Studies on health workers’ experience in Sierra Leone, N.Uganda, Zimbabwe and Cambodia showed that religion is a key motivator to join the profession and also a strong factor supporting staying in service during tough times.

So where do we go from here?

The brilliant plenary on intersectionality, showed how we need to consider multiple axes of inequity (race/poverty/gender/(dis)ability/sexuality etc.) to address power and privilege. These play out in different ways at different moments in time and in different contexts. Social justice is key, as is reflexivity and critically thinking through our own roles as researchers within health systems. There are parallels here too with the First Nations’ concept of “cultural humility” as a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Olena Havinsky, from Simon Fraser University in Vancouver, referred to the idea of “incremental radicalism”, small steps to build mutual understanding and alliances for change and to promote social justice. We need to draw on these concepts and put in place strategies to further support the holistic health and well-being of front line health workers who are the key to both responsive and resilient health systems and universal health coverage.

How to Involve Key Stakeholders and Adapt to the Local Rhythm: Lessons from the Western Region, Ghana

By Irene Tsey

[on behalf of Contextualising Lymphatic Filariasis(LF) Hotspots Research Team, DHRC.  Irene Honam Tsey is a Research Officer & Institutional Review Board Administrator at DHRC]

“This was my second time to the Western Region as well as on the field for data collection. Interestingly, I cannot believe the depth of information and knowledge gained from this trip when some years back at the same place I could not even dream of putting together this piece. I am so grateful for my experience in DHRC”

It was a long trip of about 320km and we got to our final destination almost at midnight after setting off late in the morning of that same day from Dodowa. Although very tired and not knowing exactly where to spend the night we encouraged ourselves with humour. We made jokes from previous experiences.  We spent ten days in the field and learnt first-hand the importance of involving community leaders or gatekeepers through the support of other key stakeholders and the need to sometimes adjust to uncomfortable situations for successful Community Entry and data collection.


The Need to Identify Key Stakeholders

It is very important to know the relevant stakeholders needed for your study to avoid unnecessary delays. Upon arriving in the first district the team’s first point of call was the District Health Administration. The team met the officer acting on behalf of the director and upon briefing him and others about the study the team was handed over to the officer involved which in this case was the Disease Control Officer. This officer had the data on all the communities involved in the MDAs which she willingly handed over to the team. She was also able to delegate a field technician (FT) involved with the MDA programmes and working with the Community Drug Distributers (CDDs) to assist us in reaching the CDDs.  The FT further led us to the various community leaders and also introduced us to some available and hardworking CDDs in the communities. Having support from the relevant stakeholders on the ground who are already known in the communities through their various engagements; made it easy to reach the other stakeholders who in this case are the community leaders. The team was warmly received and granted permission to go ahead with data collection.

Need to Understand and Respect the Cultural/Social Context of your Research Community

Our first community was Muslim and the FT in the person of Jonathan advised us to dress appropriately. Based on this piece of advice, some of the team covered their heads and did not wear make-up. We also wore clothes similar to those of local women to bridge the cultural gap and make them feel comfortable in our presence. We left this community better and stronger than we came and ever ready to continue on our journey of conducting sometimes rigorous research.

Need to Adjust to the Context in which Data is going to be Collected

The team was excited to have successfully entered some communities and conducted some Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs). Aunt Rose, a very active and enthusiastic CDD gladly accepted to help organise the prospective research participants and inform the chief and elders about our study and intention. The team, Aunt Rose and the Field Technician (FT) involved in the MDAs decided to seek permission from the community leaders before commencing interviews. It is an undisputed fact that final consent to participate in a study is to be given by the prospective participant nevertheless it is important to get permission of community gatekeepers which helps with community engagement. The team learnt that seeking permission from the gatekeepers made them feel appreciated as their authority and roles as custodians of their people were respected. The benefits for us on the research team, was that it made us feel comfortable and at home in these communities.


Most of these leaders expressed their support for our work and encouraged us. They highlighted that in the future providing prior notice before arriving communities would enable them adequately prepare to receive us and to also know more about our research. This demonstrated that it is not just about seeking their permission but also keeping them in on progress.

About the study:

Contextualising LF Hotspots Research is part of COUNTDOWN’s efforts to explore and identify strategies, for more effective mass drug administration to eliminate Lymphatic Filariasis, in the remaining districts with persistent transmission in Ghana.

You can see more of our work on Lymphatic Filariasis in Ghana below:




Molecular Tools for Helminth Control and Elimination: Time to Get them Out of the Laboratory, into Programmes and Policies?

By Corrado Minetti

On my way back from Ghana, where we have been testing the molecular protocols for the detection of filarial parasites in mosquitoes, in the laboratory of Mike Osei-Atweneboana at the Council for Scientific and Industrial Research (CSIR) in Accra; I had some thoughts about how far molecular diagnostics has come but also questioned how can we make it a sustainable reality to assist effectively in disease control and elimination.


DNA extraction from pooled mosquitoes for the detection of filarial worms (on the left) and an example of amplification of parasite DNA (+) with the LAMP method (on the right) (Photo: Corrado Minetti)

In order to achieve the goals of the London Declaration on Neglected Tropical Diseases for the effective and sustainable control and long term elimination of Lymphatic Filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis; the deployment of appropriate diagnostic tools is crucial at every stage of these disease control and elimination programmes from initial mapping to post-elimination surveillance. With the rapidly changing epidemiological scenario of these diseases due to the scaling up of mass drug administration, and the push towards more sustainable and cost-effective multi-disease interventions, the implementation of more sensitive and cost-effective diagnostic tools is a priority well recognized and advocated by the World Health organization.

Molecular diagnostics tools, including (multiplex) real-time polymerase chain reaction and more recent isothermal amplification assays such as loop-mediated isothermal amplification and recombinase polymerase amplification do offer increased sensitivity compared to traditional approaches but they are yet to be used in control and elimination programmes due to their cost and technical requirements. There are various gaps that need to be highlighted and solved in order to allow these approaches to become potentially embedded into disease control programmes & policies, and to inform decision-making.

In order to identify these much-needed gaps, we have recently published a review paper where we compared the features of published real-time PCR and isothermal amplification assays for the detection of Lymphatic Filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis in clinical and vector/intermediate host samples. Despite the availability of a wide range of assays for both patient diagnosis and xenomonitoring (parasite detection in insect vectors or snails), little or no research has been devoted to estimate the real costs and logistics of implementing these approaches on a wider scale for control and elimination. We highlight the need for a major focus on the implementation aspects of these tools in developing countries, and how barriers for their full adoption in resource-poor settings could be overcome. Key issues are the technical requirements and the related need for capacity building, the abatement of costs and the economic sustainability of molecular screening over time. For example, diagnosing multiple parasites from the same clinical sample can heavily reduce the number of samples that a community may need to provide, resulting in a far less invasive procedure for the communities, as well as reducing significantly the cost of processing. A multi-disease approach to diagnostics will certainly benefit the health system as well, both logistically and economically.

Writing this review paper has been extremely valuable to get a clearer picture of the progress in the field so far and to identify the best and most cost-effective diagnostic approaches for our project. In a broader sense and within the COUNTDOWN research consortium, we hope this review could serve as a starting point of discussion in the NTDs control and elimination community, leading to a more comprehensive analysis of what molecular diagnostics can offer and how we can make sure these tools can finally get out from the laboratory becoming embedded into policy, to strengthen disease control and elimination programmes and the health system itself.

Find more information on COUNTDOWN’s activities visit us here.