Developing my research question

The first step in a research project is to develop the question you seek to answer. I thought I developed my research question many months ago. In the halls of Frost Library at Amherst College; through conversations with my advisors as I worked on my undergraduate thesis on health care delivery models in South Africa; in my New York City apartment as I refined my Fulbright Statement of Grant Purpose. I don’t want to dismiss these activities, for they will certainly have contributed immensely to the development of my research question, objectives, methods and so on. However, it was through two back-to-back visits to Vulindlela, a sub-district 150 km north-west of Durban, that I feel I have truly begun the process of uncovering my research question. 

Vulindlela is a largely Zulu-speaking rural community that is home to about 90,000 residents. The HIV prevalence rate in this rural community is astoundingly high. Just under a third of women ages 25-29 are infected with HIV, and this increases to 46.8% for the cohort of women ages 30-34 (Karim et al., 2011). Among certain age cohorts, women in Vulindlela are more likely to be infected with HIV than her counterparts in Durban (an urban city). For example, a woman between the age of 30 and 34 who lives in Vulindlela is 1.4 times as likely to be infected with HIV compared to a similarly aged woman living in Durban. Her biggest risk factors: she is poor, uneducated and unable to negotiate safe sex with her partner. See the table below for a more comprehensive set of data from the study.

(Snapshot of Table 1 from Karim et al., 2011)

Vulindlela has seven Primary Health Care (PHC) clinics where nurses provide comprehensive primary care, including family planning services, voluntary HIV counseling and testing, STI treatment, antenatal care and a whole host of other services. Caprisa has been working in Vulindlela for 10 years, providing HIV prevention, treatment and care to the community at its clinical research site.

Making your research relevant

As a result of the PEPFAR transition, all NGO’s providing PEPFAR-funded care and treatment have recently been required to down-refer their patients to department of health PHC clinics. This additional patient load will likely impose a significant burden on already overstretched and under-resourced clinics. These issues are particularly pertinent when it comes to patients on antiretroviral therapy (ART), whose health depends upon adherence to their drugs and clinical management of side effects. As Caprisa transitions its patient load to the seven PHC clinics in Vulindlela, several research questions come to mind:

• What are the human resource for health figures of the seven Vulindlela PHC clinics?
• How many NIM-ART nurses are there, and how are they balanced among the PHC clinics?
• How does the level of support to NIM-ART nurses from clinicians vary by urban versus rural facilities? Does this impact health outcomes?

Vulindlela is one community among hundreds in South Africa that is facing the dual burden of imbalances of human resources for health and high rates of HIV. While private NGOs such as Caprisa have filled a critical gap for many years, the department of health is primed to step up its responsibility for health care provision. It is the confluence of these factors and events that will help shape my research questions in the coming weeks. Stay tuned!

Introducing Global Health Beat

This morning I am flying to Durban, South Africa (well, by way of Europe, for 2 weeks!), to begin a 9-month Fulbright grant in Public Health. I will be conducting independent research on the costs, benefits and impacts of HIV treatment models in South Africa.

Some food for thought

South Africa’s complex history of apartheid has shaped a landscape of enduring socioeconomic inequality and a legacy of apartheid that will live on for decades. Nevertheless, South Africa has moved forward to create a unified, democratic, “rainbow nation.” South Africa is warm, vibrant and sophisticated, I place I will feel privileged to call home. Travel the beautiful Durban beaches, Cape Town rocky coastline and Drakensburg Mountains; read about the prolific South African-based scientific research being conducted.

Despite this extraordinary progress, HIV threatens the social fabric of the country, as well as its economic and political viability. South Africans have responded to this challenge and demonstrated their will to tackle the epidemic. AIDS activists, including members of Treatment Action Campaign and others, successfully lobbied for publicly provided AIDS treatment in the early 2000s and continue to campaign for HIV education and treatment literacy to reduce AIDS stigma. They have also played a vital role in challenging the system of HIV treatment delivery.

However, 12 years after the historic Durban AIDS conference and on the heels of the first conference to return to the United States in 22 years, and we still have not turned the tide on the epidemic. South Africa is currently burdened with the most number of people in the world living with HIV and is continually challenged to meet an incredibly high demand for treatment—both for individuals and public health (more on that later). Rhetoric is not the answer.

To add fuel to the fire, PEPFAR has recently begun transitioning from financial to technical support to South Africa. In an era of constrained resources and fiscal austerity, research on ways to optimize public health dollars spent and find additional system-wide efficiencies is particularly timely.

My research

For too long, South Africa’s health policy was not adequately aligned with the health workforce and infrastructure landscape—doctors are largely concentrated in the urban hospitals and in the private sector and are in short supply in rural, disadvantaged communities where nurses run most clinics. Until 2010, initiation and management of HIV treatment, which is called antiretroviral therapy (ART), was limited to doctors practicing at accredited sites. Although publicly provided ART is free, infrastructural and resource constraints imposed substantial indirect costs on patients, including transportation costs and lost income from missed days of work. Large public hospitals accrued long waiting lists for ART and patients got sick and died waiting for treatment.

Recognizing the lingering effects of apartheid, pilot projects emerged across the country to “decentralize” HIV services to primary heath clinics through nurse-provided treatment. The results were impressive. In a study of one program in Lusikisiki township in the Eastern Cape province, TAC and Médecins Sans Frontières (MSF) showed that for every health outcome—ART adherence, viral load, mortality, loss-to-follow-up—patients managed by nurses performed as well or better than patients managed by physicians. In light of the encouraging results from these pilot sites, South African national policy is catching up. This small body of research led to policy guidance in April 2010 recommending that nurses provide comprehensive HIV/AIDS services at the primary health clinic level.

Over two years have passed since this landmark policy change, and I want to understand the costs, benefits and impacts on the health care system, individuals and communities. My research will be based at CAPRISA (Centre for the AIDS Programme of Research in South Africa), a preeminent research institute, performing rigorous studies that are guiding the development of progressive interventions and policy. Quarraisha Abdool Karim, an absolute rock star in the global health field who co-directs CAPRISA with her husband Salim, will mentor me.

I hope to use this blog as a platform to discuss global health policy and research in South Africa and beyond as well as my experience as a Fulbright student. It will be most successful if it is interactive, so please leave comments or email me if you have suggestions (Jamie.alex.cohen@gmail.com).

Thanks for reading!