Past Projects

Project Title:  REFUGE-ED - Effective practices in education, mental health and psychosocial support for the integration of refugee children

Summary: REFUGE-ED seeks to develop a Brokering Knowledge Platform of Effective Practices (BKP), which will host and promote education as well as mental health and psychosocial support solutions for the integration of migrant and refugee children in schools and more broadly in society. A process of co-creation - using a dialogic process with children, families, teachers, practitioners working on the ground, policy-makers and other relevant stakeholders, and applying a new communicative methodology developed by the consortium (SPICE) - will be applied to co-create knowledge and identify pilot actions to be carried out across multiple sites, including hot spots/reception identification centres, inclusive school environments and non-formal and informal social and learning environments, and institutional care (including unaccompanied minors). In total, the REFUGE-ED project has carried out multisite pilot actions across 6 countries (Sweden, Ireland, Spain, Italy, Greece and Bulgaria). The final co-created BKP will provide tools, solutions and recommendations, including guidelines and criteria on capacity building training, solution adaptation and community engagement in easy-to-use off-line package, in different formats, to support the implementation, reuse and scalability of the piloted actions, and of other practices identified as successful.
Partners: Autonomous University of Barcelona (AUB; Lead Coordinator); University of Florence; New Bulgarian University; Kentro Merimnas Oikogeneias Kai Paidiou (Family & Childcare Centre; KMOP), Save the Children Denmark, Danish Red Cross, Support Group Network, Associazione Culturale Cooperazione Internazionale Sud-Sud (International Cooperation South South).
Project Website: www.refuge-ed.eu
Principal Investigator(s) (TCD): Dr Frédérique Vallières (TCD Lead), Prof Teresa Sordé Martí (PI)
Contact: Dr Sadhbh Byrne (byrnes83@tcd.ie)
Funding Agency: European Commission
Programme: H2020-SC6-MIGRATION-2020 (No. 101004717)
Funding Amount: €2,997,830

Project Title: CONTEXT - The Collaborative Network for Training and Excellence in Psychotraumatology:

Summary: An international, interdisciplinary collaboration between nine European partner organisations CONTEXT is a doctoral training programme which takes place across the academic, non-governmental, voluntary, and public sectors. A total of 12 research fellows will conduct research with one of the following three Global Mental Health priority populations in Europe: (1) EU-based asylum seekers and refugees; (2) Emergency-service personnel and humanitarian first-responders; and; (3) Survivors and perpetrators of childhood- and gender-based violence. Each research project is designed to address current and emergent skill and professional deficiencies, essential for curbing the adverse social consequences of trauma-related psychological distress.
Partners: Ulster University; University of Southern Denmark; International Federation of the Red Cross, Red Crescent Psychosocial Reference Centre; Police Service of Northern Ireland; Dublin Rape Crisis Centre; Probation Board of Northern Ireland; Danish Children Centres; Spirasi
For more information: www.psychotraumanetwork.com
Principal Investigator: Dr Frédérique Vallières
Funding Agency: European Commission
Programme: H2020-MSCA-ITN-2016 (No. 722523)
Funding Amount: €3,316,000

Project Title:Perform2Scale

Summary: Perform2Scale uses a problem-based management strengthening intervention to improve workforce performance and health service delivery in three African countries: Malawi, Uganda, and Ghana. The goal of Perform2Scale is to develop and evaluate a sustainable approach to scaling up a district level management intervention in different and changing contexts.
Partner: Liverpool School of Tropical Medicine (Lead Coordinator); Royal Tropical Institute, Amsterdam; Swiss Tropical Institute; Makerere University, Uganda; University of Ghana; Reach Trust, Malawi.
Project Website: http://www.perform2scale.org
Principal Investigator (TCD): Dr Frédérique Vallières
Funding Agency: European Commission
Programme: H2020-SC1-2016-RTD
Funding Amount: €7,689,009

Project Title: Understanding and measuring pregnancy-related anxiety in low- and middle-income contexts: A pilot study in northern Ghana.

Summary:  Prenatal anxiety has been associated with poor health outcomes of mothers and children, but much of the evidence is based on high-income nations using measures that have been developed for the use in Western populations. Hence, we need first to systematically review research on prenatal anxiety in order to get a clear overview of levels of pregnancy-related anxiety and relations with maternal and neonatal mortality. Then, we will apply a bottom-up approach, using focus group discussions to investigate the domains of pregnancy-related anxiety in Ghanaian women. This will inform the adaptation and validation of a measure of prenatal anxiety that is culturally relevant and adapted to the context in Ghana. The adapted measure will be pilot tested in a survey study of 575 pregnant women in northern Ghana.
Partners: Dr Hamideh Bayrampour (University of British Columbia), Ghana Medical Help
Principal Investigators: Drs Kristin Hadfield (TCD) and Gilbert Abiiro (University for Development Studies)
Funding Agency: UK Medical Research Council
Programme: Global Maternal and Neonatal Health 2019
Funding Amount: £89,808

Project Title: FIERCE -  Evaluating the efficacy of a Jordanian shared book-reading intervention to improve early childhood education

Summary: Community-led, shared book-reading interventions can improve early childhood development and reduce inequity. One such program, We Love Reading (WLR) was implemented in Jordan in response to the Syrian refugee crisis and involved mothers reading stories to children. We will examine the potentially transformative nature of WLR, by (a) evaluating WLR qualitatively and quantitatively and (b) interviewing the people who developed and implemented WLR (WLR Ambassadors, women trained in WLR, children who too part) to create a toolkit for effectively developing and implementing non-formal education resources elsewhere. To address the first aim, we will conduct a grounded theory analysis of interviews with stakeholders (i.e. parents, children) and will conduct a quantitative randomized controlled trial with Syrian refugee women and children. This will allow us to understand how an education intervention may impact children's educational trajectories during war and displacement, and how we can effectively intervene in other humanitarian crisis contexts.
Partners: Prof. Amal A lKharouf (University of Jordan), Prof Sophie von Stumm (University of York), Taghyeer Foundation
For more information: https://www.thebritishacademy.ac.uk/projects/education-learning-in-crises-developing-implementing-transformational-intervention/
Principal Investigators: Drs Kristin Hadfield (TCD) and Isabelle Mareschal (Queen Mary University of London)
Funding Agency: British Academy
Programme: Education and Learning in Crises
Funding Amount: £359,490

Project Title:  Improving the Psychological Treatment of Refugees and Asylum Seekers who have experienced torture and other forms of extreme trauma

Summary: The growing number of refugees is of particular concern to global mental health practitioners. Specifically, refugees are more likely to be trauma-exposed, and are at least 10 times more likely to experience posttraumatic stress disorder (PTSD) compared to the general population. The current project will (i) assess the cross-cultural utility of the International Trauma Questionnaire (ITQ), as a valid and reliable tool to measure PTSD and CPTSD among torture survivors, as per ICD-11 categorisations; (ii) determine whether a diagnosis of CPTSD differentially predicts patient outcomes over time, as assessed by a range of psychological outcome measures.; (iii) determine whether using patient-centred approaches, the most appropriate and acceptable psychological treatment paths for asylum seekers and refugees who meet the diagnostic criteria for PTSD or CPTSD.
Partners: Spirasi - The National Centre for the Rehabilitation of survivors of torture in Ireland.
Principal Investigator (TCD): Dr Frédérique Vallières (PI)
Contact: Aisling Hearns (hearnsai@tcd.ie)
Funding Agency: PhD Provost Awards (TCD)
Funding Amount: €95,000

Project Title: FFPSS -  The effectiveness, mechanisms of change, and acceptability of Family Focused Psychosocial Support for at-risk adolescents in Lebanon

Summary: This mixed-method study aims to develop and evaluate a Family Systemic Intervention Module, named Sawa A2wa (Stronger Together), to use alongside UNICEF Lebanon's focused psychosocial support (FPSS) programme, to enhance current humanitarian programming and address a significant weakness of the current evidence base for at-risk adolescents and their families in conflict-affected contexts. Focused psychosocial support aims to promote wellbeing and resilience and to reduce mental ill-health in young people at risk of child protection violations, including gender-based violence, child marriage, and child labour. The immediate impact of the study is the focused support for 351 at-risk adolescents and their caregivers. Other impacts include the integration of the systemic family module into existing FPSS activities across Lebanon, and engagement with the National Mental Health Programme for longer term impact on psychosocial support provision.
Academic Partners: Dr FL Brown and Prof M Jordans (War Child Holland), Dr Maliki Ghoissany (Boston University), Dr T Betancourt (Boston College of Social Work), Prof A Carr (University College Dublin), Prof M Donnelly (Queen's University Belfast)
Technical and Implementing Partners: The Danish Refugee Council, Terre des Hommes Italia, War Child Holland, UNICEF Lebanon, the National Mental Health Program, the Global Health Institute and Community Advisory Boards
For more information: https://gtr.ukri.org/projects?ref=AH%2FT007419%2F1
Principal Investigator: Dr Tania Bosqui (TCD)
Funding Agency: Arts & Humanities Research Council (AHRC)/DFID
Programme: Development Grants
Funding Amount: £485,556

Project Title:  COVID-19 Psychological Survey 

Summary: The COVID-19 Psychological Survey is a multi-wave study running throughout the COVID-19 outbreak to better understand how people are responding, understanding, and coping with the pandemic. Data is being used to map changes in response to the evolving COVID-19 pandemic, people’s mental health, and views on COVID-19 vaccination. Three waves of data collection have taken place so far, the first of which took place two days after the initial lockdown.
Partners: Part of a six-country, international research consortium, the Irish arm of the survey is being conducted by the Trinity Centre for Global Health (Dr Frédérique Vallières), in collaboration with Maynooth University (Dr Philip Hyland), Ulster University (Professor Jamie Murphy, Professor Mark Shevlin), Edinburgh Napier University (Professor Thanos Karatzias), and University of Sheffield (Professor Richard Bentall).
Principal Investigator (TCD): Dr Philip Hyland & Dr Frédérique Vallières
Project Website: https://www.sheffield.ac.uk/psychology-consortium-covid19
Funding Agency::  Economic and Social Research Council (No. ES/V004379/1) ;with start-up funds from the University of Sheffield (Department of Psychology, the Sheffield Methods Institute and the Higher Education Innovation Fund via an Impact Acceleration grant administered by the University) and by the Faculty of Life and Health Sciences at Ulster University.

Dr Fiona Larkan and Dr Eilish McAuliffe are leading the Centre's research initiatives in the area of HIV/AIDS. Presently, we are developing initiatives which aim to address:

1. The relationship between socio-structural-environmental context and reproductive behaviour among various disadvantaged population groups in sub-Saharan Africa, notably young women in rural Zimbabwe and adolescent slum inhabitants in Anglo-phone West Africa
2. The role of adult heterosexual men in facilitating the spread of HIV has increased the need for more information to understand the dynamics between men's heterosexual behaviour and the spread of HIVAIDS in many populations all over the world. Research in this area has become more urgent given the increasing migration of young unmarried men from areas of high prevalence to areas of low prevalence.

The unprecedented economic boom of the "Celtic Tiger" has made Ireland, a country with low HIV prevalence, an important destination for migrant workers from Africa, Asia, Europe, the Middle East and South America. Since the majority of migrants are unaccompanied, it is important to investigate their patterns of sexual behaviour and the implications for the spread of HIV/AIDS and the health system in Ireland.

Project Title: How Community Conversations influence behavior change communication for health: A realist evaluation in Marsabit, Kenya.

Summary: This is a 36-month Irish Research Council Marie Skłodowska-Curie Actions (MSCA) COFUND Postdoctoral Fellowship Programme entitled CAROLINE – ‘Collaborative Research Fellowships for a Responsive and Innovative Europe’. As part of CAROLINE, fellows will focus research on aspects of the Sustainable Development Goals (SDGs) and have inter-sectoral, international collaboration. This project will use realist evaluation methodology to understand how an NGO implemented intervention aimed at community systems strengthening and behaviour change works, for whom, and why, within Marsabit County, Kenya.
Partner: Concern Kenya, Concern Worldwide, World Health Organization
Principal Investigator(s): Dr Brynne Gilmore & Dr Frédérique Vallières
Funding Agency: Irish Research Council and European Commission
Funding Amount: €200,000

Project Title:  SPHEReS  - Strengthening Post-graduate Health Education and Research in Sudan

Summary:  Strengthening the management, performance, education and training of Human Resources for Health are all identified as priority areas in Sudan’s National Health Sector strategies (2012-2016). Aligned to the mission and strategic direction of the Sudan Medical Specialisation Board (SMSB), to improve the performance of the health system through standardised and monitored training, accredited training sites, qualified and committed trainers, and competent professional trainees, a new partnership was proposed between the SMSB and the Centre for Global Health, Trinity College Dublin.
Partner: Sudan Medical Specialization Board
Principal Investigator(s): Dr. Ayat Abu-Agla & Dr. Frédérique Vallières
Funding Agency: ESTHER-Ireland
Funding Amount: €8,000

This project is funded by World Vision, Irish Aid and DfID.

Aim

Assessing the use of community-based approaches to improve maternal and child health through addressing the most common preventable causes of infant and maternal morbidity and mortality. 

Background

Growing enthusiasm around information communication technology for development (ICT4D) has sparked international interest and large investments in mobile phone projects across the globe.  This technology has the potential to increase health service delivery; strengthen health information systems; improve data collection and monitoring; and provide support for health workers. The evidence demonstrating the impact of mobile phones as a human resource management tool for CHWs however, remains scarce.

The Trinity Centre for Global Health is partnering with the Ministry of Health and Sanitation Sierra Leone, World Vision Ireland and World Vision UK to improve maternal, newborn and child health in Bonthe District, Sierra Leone.  Through grants from both Irish Aid and DFID, 33 CHWs will be trained in the delivery of the 7-11 timed and targeted counselling strategy. 7-11 is an evidence-based framework delivering 7 key health interventions for pregnant women and 11 key health interventions for children under 2.

The main objective of this study will be to carry out a piece of operational research to assess changes in health worker motivation over time, triggered by the introduction of a mobile phone application for 7-11 timed and targeted counselling as a specific human resource management tool.  Motivation will be looked at in conjunction with performance indicators (i.e. referral rates, missed visits), supportive supervision, job satisfaction, and organisational commitment, all of which will serve as indicators of future attrition rates for the community health worker programme. 

Fig. 1 TTC Visit Schedule

Funded by ESRC/DiFD

This research project is jointly co-ordinated by Professor Stuart Carr, Poverty Research Group, Massey University, New Zealand and Professor Mac MacLachlan, Trinity Centre for Global Health, Trinity College Dublin, Ireland. According to the Paris Declaration best practice in aid work means pay should be aligned and harmonised across worker groups (World Bank, 2005). Although pay may not be a primary motive for development workers, discrepancies in pay nonetheless have the potential to influence perceptions of organisational justice, which can in turn affect work performance. Moreover, because injustice is a motivation for much aid itself, perceptions of unfairness in aid work may have an inherent salience and undermine its necessary constituents, especially cooperation and capacity building. This project explores the effects of aid salary discrepancies in the health, education and business sectors of six countries: the landlocked economies of Malawi and Zambia; the transition economies of India and China; and the island economies of the Solomon Islands and Papua New Guinea. Bringing together an international team of psychologists and sociologists from 10 different countries this project focuses on the human dynamics of aid salary discrepancies and their significance for capacity building in low-income countries.

Dual Salaries and Project ADDUP: Are Development Discrepancies Undermining Performance?

A fair day’s work for a fair day’s pay.  
Carlyle’s adage reminds us that decent remuneration is integral to the International Labour Organisation’s “Decent Work Agenda.”  Yet in many lower-income settings, there is a glaring institutional inequity:  Dual salaries. Compared to local colleagues performing the same or similar jobs, expatriate workers are usually paid much more. 
This double standard is not simply about gaps in skills or experience. Many lower-income countries have invested well in local education and training since Independence. International salaries are higher mainly because expatriates originate from higher-income economies, and labour markets.  The resultant gaps contravene Paris and Accra declarations on aid effectiveness, which instead promote harmonisation and alignment. They are also, arguably, discriminatory.

An Elephant in the Development Parlour. 
Contravention of initiatives to improve the effectiveness of aid may partly explain why the topic remains taboo - and under-researched. Project ADDUP acknowledges the elephant in the parlour, and breaks the silence. A multi-disciplinary study reflects the voices of over 1300 professional workers and community representatives from 200 aid, government, educational and business organisations in land-locked (Malaŵi, Uganda), Oceanic (Solomon Islands, Papua New Guinea) and emerging economies (India, China). 
ADDUP systematically explores the human dynamics of dual salaries, by: (a) documenting the extent of salary discrepancies; (b) exploring their consequences for work performance; and (c) determining the potential for salary alignment and harmonization to boost cooperative work performance, build capacity and more effectively reduce poverty. 

The Project
We began by asking workers to provide “critical incidents,” or work stories, about dual salaries and their daily impacts on capacity development. Based on these incidents, we designed a radically new survey instrument. Participants answered questions about their remuneration levels and standard of living, remuneration-comparison, -justice, -motivation, job satisfaction, work engagement, turnover and thoughts about global mobility. We ran control measures of cultural values, culture shock, and a range of demographic variables, e.g., gender, highest qualification and years’ experience.  At the conclusion of the survey phase we took the data back to the communities from which they were lent. There, subject-matter-experts and key stakeholders interpreted our initial analyses of the data for their practical and moral value.

Local Relevance
The main findings are that: (a) excluding a negligible number of local respondents on international remuneration and expatriates on local pay, ratios in purchasing power between international and local pay average 4:1, leaving most local workers in economic need. The greatest disparity occurred in Island Nations (approaching 9:1); the least in emerging economies (approximately 2:1); with landlocked nation’s in-between (3:1). 
Multi-level modeling highlighted a resultant (b) sense of injustice among the locally-remunerated workers, which was the major predictor of work motivation/de-motivation. This together with job satisfaction and work engagement predicted turnover and international mobility intentions - brain drain.
According to subject-matter experts who interpreted the findings via in-country workshops, these data indicate that (c) closer harmonization and alignment of dual salaries would reduce poverty directly among workers, boost cooperative work performance, build capacity, and help reduce poverty. A range of technical options for closing the gap, and enhancing equity, were suggested.

Global Dissemination
These findings are set to appear in the peer-reviewed flagship journal of the International Union of Psychological Science, the International Journal of Psychology (2010). The findings have reached a range of workshops and keynote addresses at development-related conferences, such as the Annual Global Development Network meeting (2008) and at the “Psychology Serving Humanity” conference in Cape Town, by the international Union of Psychological Science (for 2012).  
The findings from addup also inspired a ground-breaking new book, The aid triangle: recognizing the human dynamics of dominance, justice and identity (May 2010, MacLachlan, Carr & McAuliffe, Zed Books, London and New York). 

Impact
Project ADDDUP has been instrumental in the setting-up of a first Global Task Force for Humanitarian Work Psychology (http://www.humworkpsych.org). This is an international network of researchers and practitioners from lower-, middle- and higher-income countries, whose goal is to promote and build capacity by applying humanitarian principles in work settings through multilateral bodies such as the United Nations and the International Labor Organisation, as well as with policy think-tanks like the Organisation for Economic Cooperation and Development (OECD). 

The Task Force has just submitted our first full submission to the United Nations through its call for fresh perspectives on Keeping the Promise (UN, 2010). We argue that organisations have become a forgotten entity in the development equation, falling between the twin stools of macro-economic policy and micro-psychological analysis. 

Our data from Project ADDUP clearly suggest that organisations can be points of intervention to enable a fair day’s work for a fair day’s pay. 

Acknowledgment

Project ADDUP was funded through the ESRC and DFID Joint Scheme for Research on International Development (Poverty reduction). 

One-minute Elevator Test

The project identifies a range of barriers to basic capability and capacity development, taking place in workplaces across a range of sectors, due to dual salary policies:  (1) remuneration leaves locally-salaried workers, chiefly local people, below the poverty line, defined as not meeting everyday needs; (2) technical cooperation is impeded by the sense of injustice and comparative disadvantage that permeate dual salary systems; (3) organisational climate is a moderator of the linkages in (2), implying that organisations can become points of intervention to render pay and benefits more fair, and thereby improve human services, productivity, and poverty reduction itself. The UN’s latest publication Keeping the Promise of the Millennium Development Goals calls for greater attention to organisations, and the human factors in them.

This five year Ireland Africa Partnership, started in 2008, focuses on pro-poor research to address the Health MDGs: reducing child mortality; improving maternal health and controlling HIV/AIDS, malaria and other infectious diseases.

The goal of the Partnership, in support of the Government of Ireland’s development goals, was:

• to build research capacity in Ireland and Africa and
• to conduct research that strengthens health systems in Africa to serve the poor more effectively 

The main Programme themes were:

•  Governance: research that contributes to strengthening the capacity of government institutions and the involvement of civil society and other stakeholders in providing services that meet the health needs of the poor.
• Human resources for health: research to identify strategies for ensuring that health workers are available, able and motivated to deliver health services, especially to those who are poor or marginalised.
• Access and Equity: research that contributes to understanding and overcoming barriers that the poor and other disadvantaged groups experience in seeking to access health services.

Partners included: Trinity College Dublin, The Royal College of Surgeons in Ireland, The National University of Ireland Galway, the Malaria Consortium, and Institutes in Lesotho, Malawi, Mozambique, Sierra Leone, Sudan and Uganda.
Year 1 activities involved research mapping through reviewing country literature on key themes, awarding PhD scholarships and training PhD candidates, and building local research capacity.

For further information on this research project please contact Dr Steve Thomas, TCD Principal Investigator.

A-PODD (African Policy on Disability and Development) was a three-year qualitative research project, funded by a €500,000 research grant from the Health Research Board/Irish Aid. A-PODD was led by Prof Malcolm MacLachlan, Trinity Centre for Global Health and School of Psychology, Trinity College Dublin.   The Trinity Centre for Global Health’s primary coordinating partners on this project were Ms. Gubela Mji at the Centre for Rehabilitation Studies, Stellenbosch University and Mr. Kudakwashe Dube at The Secretariat of the African Decade for Persons with Disabilities, South Africa.

This research investigated the need for disability to be included on the agenda of national and international development initiatives. It aimed to document and analyse the factors that contribute to realising the rights of disabled people, promote their health and well-being and release their economic potential, with government strategies aimed at poverty alleviation.  It focused on how research evidence can be utilised to inform the policy environment (such as PRSPs and SWAps), and development institutions (such as the IMF, World Bank and WHO).  The research also focused on less formal local, community and grass-roots decision-making and inclusion efforts.  

A-PODD undertook four country-case studies:  

Sierra Leone, a country emerging from conflict that resulted in many people being disabled;

Malawi and Uganda, the only two African countries that have Ministries for people with disabilities;

Ethiopia, the second most populous country in Africa, with significant geographical barriers and a highly dispersed population, presenting significant challenges to the inclusion of people with disability. 

The disabled people in Africa constitute a valuable resource for economic growth, if this economic potential can be realised.  Key to this is their access to healthcare, education and housing.  In addition to promoting innovative redistribute policies, the project sought to involve disabled people as part of the economic solution to achieving the Millennium Development Goals (MDGs), particularly poverty reduction. 

Recently, the approach to disability has changed dramatically from a charitable, paternalistic and biomedically-based ‘caring-for’ approach. This approach recognises the human rights of disabled people and their need for advocacy and empowerment, in order to fully participate and be included in society. 

A comparative analysis informed the disability policy within the region. Factors which restrict or facilitate these policies were identified along implementation pathways, as were local means and mechanisms of addressing them. Country reports were discussed at the concluding workshop to which governments, civil society, donors, researchers and others were invited. A code of best practice wes drawn up for Moving Evidence to Action on African Disability Policy.

The A-PODD (African Policy for Disability and Development) website has now been established (www.a-podd.org).  There is an interactive function on the A-PODD website and we would be pleased if you would like to 'post' any comments or suggestions. The public may register on this website, so we will have a database of users that we can communicate with also. 

Post-Doctoral Research Fellows (based in Stellenbosh University): 

Dr. Margaret Wazakili (mwazakili@sun.ac.za) 

Dr. Tsitsi Chataika (tchataika@sun.ac.za) 

Project Co-Ordinator: (based in Trinity College Dublin): 

Mrs. Marcella Maughan

For further information on this research project please contact Prof. Mac MacLachlan

The consortium was led by Professor Mac MacLachlan (Trinity Centre for Global Health & School of Psychology), with Trinity Co- Investigators, Dr. Hasheem Mannan (National Institute for Intellectual Disability & School of Social Work & Social Policy) and Eilish Mc Auliffe, (Trinity Centre for Global Health & School of Medicine).

The consortium partners were:

• Afhad University for Women (Sudan)
• University of Malawi Centre for Social Research (Malawi)
• Human Sciences Research Council (South Africa)
• Secretariat of the African Decade for Persons with Disabilities (South Africa)
• The Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF) (Norway)
• University of Stellenbosch Department of Psychology and the Centre for Rehabilitation Studies (South Africa)
• University of Namibia Multidisciplinary Research and Consultancy Centre (Namibia).

This research programme recognized that health services cannot hope to be equitable unless they are equally accessible to all. The project contributed to achieving the Millenium Development Goals (MDGs) by addressing the health service needs of some of the most disadvantaged people in Africa. Conceptualizing disability along a continuum of activity limitation the programme explored the interplay between disability and other factors that marginalize and exclude people from mainstream services and society. EquitAble used policy analysis along with qualitative and quantitative empirical research methods to contribute to a rigorous evidence-base that aims to bridge the know-how gap for national, regional, and international health policies and practice.

For further information on this research project please contact Prof. Mac MacLachlan

Project Website: http://www.equitableproject.org/

Funded by Irish Aid and the Ministry of Foreign Affairs, Denmark.

The human resources for health crisis in Africa demands innovative and locally appropriate solutions that increase access to quality health care at a price affordable to governments. One such solution is the development and deployment of mid-level providers as seen in many countries throughout Africa over the past four decades. These mid-level providers typically perform critical functions conventionally associated with more highly trained and highly mobile health providers and, compared to doctors, are more likely to be present at district level health facilities especially in rural areas.

Yet, despite apparent broad use of mid-level providers in Africa, these health workers are virtually invisible in policy documents and government strategic plans; there are few efforts to expand their training; and little is known about their current use and practice or even about the factors at individual, organisational, and environmental levels that enable or block their performance. To address this need, a consortium of four research, advocacy and policy focused organizations have formed a strategic partnership to implement the proposed project, Health System Strengthening for Equity: The Power and Potential of Mid-level Providers (HSSE). This is a four year, multi-country project that builds on the growing policy momentum and global dialogue to address the human resource crisis and the need to support functioning, responsive health systems. The four partner organizations are Trinity College Dublin Trinity Centre for Global Health (CGH), Columbia University's Mailman School of Public Health Averting Maternal Mortality and Disability Program (AMDD), Realizing Rights: the Ethical Globalization Initiative (RR:EGI), and the Africa-based Regional Prevention of Maternal Mortality network (RPMM).

HSSE Project Goal and Objectives

The goal of the Health System Strengthening for Equity project was to support health system strengthening for equity in Africa by building an evidence base on the role of mid-level providers in maternal and neonatal health and promoting greater political leadership and critical policy action on this issue. The strategy that drives this Health Systems Strengthening for Equity (HSSE) project had multiple elements:

• a) a unique and strategic collaborative partnership among research, policy and advocacy organizations, and among northern and southern institutions;
• b) an approach to collaborative research that builds and supports capacity in countries and that respects the principle of country ownership of its data;
• c) an approach to collaborative advocacy that builds capacity of both southern and northern institutions to use evidence for policy and to link global and national processes and debates in order to generate more realistic and sustainable solutions; and
• d) a commitment to supporting (and not undermining) ongoing policymaking processes and to ensuring the development of policy-relevant evidence and analysis.

The HSSE project focused on the delivery of emergency obstetric and newborn health care (EmONC) by mid-level health workers as a key entry point to assessing the use and effectiveness of mid-level providers more broadly. A multi-country approach enabled in-country analyses and cross-country comparisons. The main focus countries were Malawi, Mozambique and Tanzania as each country has well established cadres of mid-level providers delivering the bulk of emergency obstetric care (including caesarean sections).

Project Website: http://www.midlevelproviders.org/

The LEARN Project focused on addressing the challenges of organisational learning in international aid organisations. The project was funded by the Irish Research Council for Humanities and Social Sciences and had two corporate partners: Irish Aid and Concern. The Learn Team comprised four academic supervisors and four PhD students. We were interested in developing understanding and practical action for organisational learning. This involved researching the role of organisational sub-cultures (Lorraine Mancey), working relationships (Sarah Barry), advocacy and action research in relation to strengthening organisational learning systems. The LEARN Project was led by Prof. Mac MacLachlan (Principal Investigator).

The use of realist methodologies in Ireland is growing. This methodology can be both rewarding and challenging. The Trinity Centre for Global Health in Trinity College Dublin has established a working group for researchers currently using realist methods to provide peer support for this process. The Realist Researcher (Support) Group aims to provide a platform for realist researchers to share experiences and trouble-shoot the methodology with others involved in the field. Meetings will be held in Dublin, and the group is open to all individuals currently engaged in realist research both in academic and practice settings. Within the Trinity Centre for Global Health, we have partnered with World Health Organization (WHO) and World Vision Ireland using realist methodologies for reviewing evidence, programme evaluation and making recommendations. We have completed two commissioned, large-scale realist syntheses and have several other realist project underway as part of PhD research. For more information, or if you wish to join the group please email Jessica Power at odowdje@tcd.ie or Brynne Gilmore gilmorb@tcd.ie.

Community health Committees in Tanzania and Uganda. 
Abstract: Strengthening community actions to improve participation in health is an essential part of health promotion and health systems strengthening. To this end, community health committees (CHC) are frequently utilised in low-income countries (LICs) to achieve a specific goal and build community capacity. Though some evidence is available on CHC’s contribution to health outcomes, currently unknown is how, and to what degree, such committees are most effective in building community capacity for improved health.  This research therefore sought to explore how CHCs work to build community capacity by conducting a realist evaluation across multiple case studies in Tanzania and Uganda. Preliminary findings have been reported across several dissemination channels (see Publications below). 
Contact: Brynne Gilmore

When Scaling Up How are Health Interventions Modified to Fit Local Settings: A Realist Synthesis. 
Abstract: Health interventions are scaled up across diverse settings with differing needs and resources. In practice, modifications are often made to address this diversity however the processes used to make these decisions have not been fully researched.

This research is using a realist synthesis methodology to explore what processes were used across case examples of scale up to make decisions on modifications to the content of the intervention, context or delivery strategy. By using realist methodologies the research aims to discover under what circumstances these processes were used and what mechanisms and outcomes took place. This research has two phases with the first examining secondary data of published examples of scale up to develop and refine theories on these processes. The second phase will complete stakeholder consultations with health implementers to further refine and test these theories.
Contact: Jessica Power odowdje@tcd.ie

Research For Health in Humanitarian Crises (R2HC) seed funding: In collaboration with Liverpool School of Tropical Medicine (LSTM), University College Dublin (UCD) and International Medical Corps (IMC) in Turkey, Iraq and Lebanon, this work sought to understand the motivation and performance of community health workers (CHWs) within conflict settings. The CGH was awarded seed funding from the R2HC programme co-funded by DFID and the Wellcome Trust to develop an initial theory using realist evaluation and to propose a three-country realist evaluation for theory refinement.
Contact: Brynne Gilmore

WHO Commissioned Research: Guideline Recommendations for the Work Force for Community Based Rehabilitation in Less Resourced Settings: A Realist Synthesis.
This research sought to identify best practices for human resources for health-related rehabilitation within the overall context of health systems strengthening. It has a particular focus on the integration and decentralization of the rehabilitation workforce within the health systems of less resourced settings. 
Contact: Brynne Gilmore

WHO Commissioned Research: Guideline Recommendations for Leadership and Governance for Health-Related Rehabilitation in Less Resourced Settings: A Realist Synthesis. This research aimed to identify best practices for leadership and governance (with a particular focus on policies) of health-related rehabilitation within the overall context of health systems strengthening. Our approach to establishing good policy practices has been to undertake a systematic literature review, a realist interpretation of the literature and a Delphi sampling of expert opinion; and to synthesize these to answer questions posed in the commissioning of this research.
Contact: Joanne McVeigh

Funded by the Advisory Board of Irish Aid.

This research was exploring the critical factors influencing human resource capacity to deliver equitable effective health care efficiently at the district level. The identification of constraints to HR planning and management at the district level as well as the key factors influencing staff retention and attrition contributed to the development of more effective human resource strategies that ultimately strengthen health systems at the district level. The research identified the critical factors influencing human resource capacity and performance at the district level. The research was focused on the District Health System (DHS) as the vehicle for the delivery of primary health care. As the research was concerned with motivational factors amongst conventional health workers and new cadres of health workers, the research population included district health managers, doctors and nurses (as the predominant conventional health workers) and new cadres of health workers (which include medical assistants, extension and community workers) working at DHS level.

Preparatory work was undertaken with Ministry of Health and district level personnel in Malawi to actively engage key stakeholders in the design of the research, in the interpretation of the findings and in the formulation of practical recommendations to improve human resource performance at the district level. This was in keeping with the action research methodology adopted in this research. A key contribution of the research process was its potential to build institutional research capacity to work in partnership with the health services towards finding practical solutions to difficult problems. This approach increased the likelihood of service improvements resulting from the research because of the shared ownership of the problem and the greater understanding generated through an active, ongoing involvement with the principal researchers. It also had greater potential (than traditional research approaches) to bridge the research to policy gap because ongoing dialogue with policy makers is inherent to the process. The work was focused on Malawi and Lesotho.

Collaborating Partners

• Department of Community Health, College of Medicine, University of Malawi
• Ministry of Health and Social Welfare, Lesotho
• Faculty of Health Sciences, National University of Lesotho
• Irish Aid Lesotho
• Centre for Health Informatics, The University of Dublin, Trinity College
• Department of Health Promotion, National University of Ireland, Galway
• Health Policy Unit, London School of Hygiene and Tropical Medicine

The Research Team

The MaxHR Project was led by Prof. Eilish McAuliffe, Principal Investigator.

There is a growing need to strengthen health systems in poor countries to help meet the Millennium Development Goals (MDGs).  The challenge is made more difficult by the demands of the AIDS crisis, migration of skilled professionals to high income countries and low morale and motivation of remaining staff. These have combined to generate a rapid worsening of availability and quality of care. Improving the retention of health workers in developing countries is critical for health system performance. Consequently, this project focused on improving understanding of how best to motivate and retain health workers. 

Motivation Project Goal and Objectives
The goal of the Motivation Project was to strengthen the evidence base for effective human resource strategies in developing countries. The project explored current capacities and contexts in three countries (Malawi, South Africa and Tanzania), evaluated local and national retention initiatives and explored in detail motivation and aspirations of health workers.

The objectives of the study were:

• To understand better the incentive and motivation environment facing health workers in district health service settings
• To assess the impact and relative importance of incentive initiatives that aim to improve recruitment, motivation and retention of health workers
• To improve the understanding of the absolute and relative power of financial and other incentives for different cadre levels

The systematic review of the literature indentified seven motivational themes, namely: financial rewards, career development, continuing education, hospital infrastructure, availability of resources and recognition/appreciation.  While these factors are undoubtedly country specific, financial incentives, career development and management issues were core factors. Nevertheless financial incentives alone are not enough to improve morale.

Component Two evaluated financial and non-financial initiatives that are being used to motivate and retain health workers. Several themes emerged across the countries and it is apparent that while financial incentives do boost motivation to a certain extent, these effects are short lived and they also lower morale for those who do not benefit. In some countries there are lots of different incentives, many of which are not complimentary and so there is a strong case for consolidation and harmonization with close attention to monitoring and evaluating the effects.

Finally a discrete choice experiment (DCE) was used to improve understanding of the relative power of financial and non-financial incentives. It was found that the relative importance of different motivational incentives differs between countries; however, training opportunities and salary are the most important overall.  Doctors and registered nurses are less motivated to work in rural areas.
All three components reinforced four main findings, namely:

1) Developing training opportunities would be a powerful motivational incentive.
2) Satisfied health workers are less motivated by financial incentives
3) Health workers, especially the higher cadres, may need to be compensated to persuade them to work in rural areas.
4) Clear communication and careful implementation is needed when using incentives so as to manage expectations.

Collaborating Partners

• Department of Community Health, College of Medicine, University of Malawi, Blanytre
• Centre for Health Policy, University of the Witwatersrand, Johannesburg
• National Institute for Medical Research (NIMR), Dar es Salaam
• Department of Epidemiology and Preventive Medicine, Royal College of Surgeons, Dublin

The Research Team

The Motivation Project was led by Prof. Charles Normand, Principal Investigator