Consideration of harmful

unintended consequences
during planning and
implementation of Project
SHINE in Tanzania:
A Case Study

Allen-Scott, L.K., S. Bastien, J.M. Hatfield and M. Manyama

21st Canadian Conference on Global Health 2014

Inspiration

WHO Clinical Practice Guidelines (2006)

Presumptive Diagnosis and Treatment

Inspiration

Malaria as a patient preferred diagnosis

Variations in Malaria epidemiology

Peer-pressure to not miss a Malaria case

Laboratory Diagnostic Capacity + Trust

OVERDIAGNOSIS
OF MALARIA

Development of
Drug Resistance

Drug Shortages

Economic Costs
to
Patient/Health
System

Under-diagnosis
of non-malaria
febrile illness

(Allen-Scott et al. 2014; DAcremont et al. 2009; DAcremont et al. 2010; English et al. 2009; Chandler et al. 2008)

Inspiration

Key Gaps
Why doesnt it
work?
For whom?
Under what
circumstances?

Absence of
harmful UC
definition and
typology for
PHI

Limited
synthesis of
PHI harmful
UC

LMIC evidence
gap

Need for PHI

planning and
evaluation
guides to
assess
harmful UC

(Christakis 2009; Ioannidis and Lau 2001; Bernal-Delgado and Fisher 2008; Garner, Kramer et al. 1992)

All too often, practitioners of public health have

been more concerned with the evidence of
effectiveness of interventions than with the
potential adverse effect of the interventions

David McQueen 2014

Framework

Actions of individuals should only

be limited to prevent harm to other
individuals Mill 1859

Unintended Consequences of
Purposive Social Action
- Merton 1936

Precautionary Principle if an action has suspected

risk of causing harm in the absence of scientific
consensus the burden of proof that it is not harmful
falls on those taking an action
Rio Declaration 1992

Framework

(Allen-Scott et al. 2014)

How can we improve identification and

minimization of unintended harms?

Framework

Pragmatism

POSITIVISM
Determination
Reductionism
Empirical
observation and
measurement
Theory verification

ADVOCACY/PARTICIPAT
ORY
Political
Empowerment
oriented
Collaborative
Change oriented

Socio-ecological Model

CONSTRUCTIVISM
Understanding
Multiple participant
meanings
Social and historical
construction
Theory generation

PRAGMATISM
Consequences of
action
Problem-centered
Pluralistic
Real-world practice
oriented

(Creswell 2009; Bronfenbrenner 1979)

Methods

WHO (2009) SYSTEMS THINKING FOR HEALTH SYSTEMS STRENGTHENING

Transdisciplinary think tank for stakeholder engagement

Expertise in the
Health Issue
i.e. academics
Expertise in Harmful
Unintended
Consequences

Influence and
Commitment

i.e. policy makers

Responsibility and
Authority
i.e. implementers

i.e. critics

Potential
Harmful
Unintended
Consequences
and Solutions

(WHO 2009; Bartholomew 2011)

Diverse perspectives
including the
community
i.e. intervention
target population

Methods

Adaptations to WHO (2009) Think Tank Steps

Describe the components of the intervention to the

transdisciplinary team

Identify underlying factors and potential harmful UC

and prioritize

Recommend adaptations to the intervention to

account for the potential harmful UC

Conceptualize the influence and interaction of

underlying harmful UC factors and redesign
(WHO 2009)

Case Study: Project SHINE

COMMUNITY-BASED PARTICIPATORY RESEARCH

Case Study: Project SHINE

CAPACITY BUILDING EMPOWERMENT SCIENCE EDUCATION

Case Study: Project SHINE

The Think Tanks

Academic (N=20)
Composition: Veterinary
Medicine and Public
Health Faculty, Medical
Doctors, Students
(undergraduate and
graduate) and Local
Research Staff

Community Leaders (N=5)

Composition:
Headmasters, Teachers
and Traditional leaders

Diverse Perspectives (N=7)

Composition: Parents,
Students and Womens
group

Factors Associated with Unintended Harms

Fix something that isnt broken?
Context

What else needs to

be considered for
your community?

Immediate Interest
Where does
sanitation and
hygiene fit in your
priorities?

Limited Knowledge

Basic Values

What can be learned

from previous
programs?

What is good and

bad about these ideas
for the community?

Do we know what cultural or

Improving knowledge when the
historical practices are currently
structural components for water
working?
and latrine are not in place will
cause long-term harm
not everyone can have a
toilet
or enough
supply
Maybe
leaveswater
are better
than
the quality of toilet paper

takes a long time and we are

dealing
when itwith
comes
to sanitation
it is
critical
issues like
critical
water
a problem
for
health
its aisvery
sensitivesoone
sanitation,
water
is not
and it takes
a lot
of just an issue
it isconsiderations.
a problem. If we
Soplace
bring in the
importance
of water and there is a
local ideas
shortage.. Then sanitation will go
down
to zero
Basing
things solely on hospital
records means that we do not
We
dont
havethe
water
supply
really
know
incidence

Potential Unintended Harms

What are you most worried about?

CULTURAL

Empowerment of a group that does not have power may

lead to conflicts of power and cultural pushback

ECONOMIC

Limited resources (poverty) in community may lead to

trade-offs

ENVIRONMENTAL

Possible negative impacts on wildlife AND water availability

OR water quality

PHYSICAL

Possible increased chance of infection from toilets if not

kept clean due to an absence of water

POLITICAL

Mobilizing youth without policy level support may lead to

conflict

PSYCHOSOCIAL

OMMISSION

Knowledge with the inability to overcome resource barriers

may lead to disempowerment/helplessness

Missing important populations: youth not in school,

primary school children, TBAs and ten cell leaders

Recommendations for Harm Minimization

Emphasize the Resiliency Model

how do current practices contribute to health?

Engage male leaders and head of households to reduce

intergenerational and gender power struggles
Link with policy makers and NGOs working in the area
to improve access to clean water
Include TBAs, primary schools and the ten cell leaders
during scale-up

Unintended
Harm Think
Tank for
stakeholder
engagement

Conceptual Map for Intervention Adaptations

Examine current
historical or cultural
practices that
promote sanitation
and hygiene

+
Primary Schools
Pastoralist Council
TBAs
Male head of
household
NGOs

Minimization of:
Disempowerment
Cultural push-back
Harm by Omission
Power imbalances

Water Access?
Poverty?

Harm
minimization

Limitations

Transdisciplinary think tank for stakeholder engagement

Partnership
Strength

Expertise in the
Health Issue

i.e. academics
Expertise in Harmful
Unintended
Consequences

Influence and
Commitment
i.e. policy makers

Responsibility and
Authority
i.e. implementers

i.e. critics

Potential
Harmful
Unintended
Consequences
and Solutions

(WHO 2009; Bartholomew 2011)

Diverse perspectives
including the
community

i.e. intervention
target population

Value?

Explicit utilization of the

theoretical and practical
frameworks may assist in
efforts to minimize public
health intervention unintended
HARM
and improve
evidence of effectiveness

http://static4.depositphotos.com/1007959/349/i/950/depositphotos_3490111-Consequences-Green-Road-Sign-Over-Storm-Clouds.jpg

University of Calgary:
Dr. Jennifer Hatfield
Dr. Lynn McIntyre
Dr. Guido van Marle
Dr. Chris Thomas
Dr. Tyrone Donnon
Dr. Sheri Bastien
Dr. Frank van der Meer
Dr. Karin Orsel
Dr. Susan Kutz

Catholic University of Health and Allied

Sciences in Tanzania:
Dr. Mange Manyama
Elias Charles
Eveline Konje
Local Community Partners
Godwin Olemshumba
Leyaro Kimani

Selected References

Allen-Scott, L. K., J. M. Hatfield and L. McIntyre (2014). "A scoping review of unintended harm
associated with public health interventions: towards a typology and an understanding of underlying
factors." Int J Public Health.
Arksey, H. (2003). "Scoping the field: services for carers of people with mental health problems."
Health & Social Care in the Community 11(4): 335-344.
Bernal-Delgado, E. and E. S. Fisher (2008). "Abstracts in high profile journals often fail to report
harm." BMC Med Res Methodol 8: 14.
Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA, Harvard
University Press.
Chandler, C. I., C. J. Drakeley, H. Reyburn and I. Carneiro (2006). "The effect of altitude on parasite
density case definitions for malaria in northeastern Tanzania." Trop Med Int Health 11(8): 11781184.
Christakis, N. A. (2009). "Only Connect Indirectly doing harm." British Medical Journal 339: -.
Creswell, J. W. (2009). Research Design: qualitative, quantitative and mixed methods approaches.
Thousand Oaks, CA, Sage Publications, Inc.
D'Acremont, V., C. Lengeler and B. Genton (2010). "Reduction in the proportion of fevers associated
with Plasmodium falciparum parasitaemia in Africa: a systematic review." Malar J 9: 240.
D'Acremont, V., C. Lengeler, H. Mshinda, D. Mtasiwa, M. Tanner and B. Genton (2009). "Time to
move from presumptive malaria treatment to laboratory-confirmed diagnosis and treatment in
African children with fever." PLoS Med 6(1): e252.
English, M., H. Reyburn, C. Goodman and R. W. Snow (2009). "Abandoning presumptive antimalarial
treatment for febrile children aged less than five years--a case of running before we can walk?"
PLoS Med 6(1): e1000015.

Selected References

Garner, P., M. S. Kramer and I. Chalmers (1992). "Might Efforts to Increase Birth-Weight in
Undernourished Women Do More Harm Than Good." Lancet 340(8826): 1021-1023.
Ioannidis, J. P. and J. Lau (2001). "Completeness of safety reporting in randomized trials: an
evaluation of 7 medical areas." JAMA 285(4): 437-443.
Levac, D., H. Colquhoun and K. K. O'Brien (2010). "Scoping studies: advancing the methodology."
Implement Sci 5: 69.
Merton, R. K. (1936). "The Unanticipated Consequences of Purposive Social Action." American
Sociological Review 1(6): 894-904.
Pawson, R., T. Greenhalgh, G. Harvey and K. Walshe (2005). "Realist review--a new method of
systematic review designed for complex policy interventions." J Health Serv Res Policy 10 Suppl 1:
21-34.
Rose, G. (1985). "Sick individuals and sick populations." Int J Epidemiol 14(1): 32-38.
Whittemore, R. and K. Knafl (2005). "The integrative review: updated methodology." Journal of
Advanced Nursing 52(5): 546-553.
WHO (2009). Systems thinking for health systems strengthening. A. f. H. P. a. S. Research. Geneva,
Switzerland, WHO.
WHO (2010). A conceptual framework for action on the social determinants of health: Social
determinants of health discussion paper 2. WHO. Geneva, World Health Organization.
Wong, G., T. Greenhalgh, G. Westhorp, J. Buckingham and R. Pawson (2013). "RAMESES publication
standards: realist syntheses." BMC Med 11: 21.