Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

So we're about to start the research skills breakout session If everyone would like to take a seat and have a listen, Um, so this aim is to just highlights the importance of global health research and to address the unmet needs of L. M. I C communities by doing relevant research to strengthen healthcare systems. And we have two fantastic speakers for you today, Um, myself, Sarah the obstetric rep for Ireland. And we have I'm Fiona. I'm one of the anesthetic reps in the UK We've got two great speakers at first coming up, and Sara will introduce, so our first speaker is like, Oh, she's a pediatric surgeon at the Children's Hospital in Oxford and the University of Oxford. She's an honorary professor at University of With Water and you know, Harrisburg and Muhimbili University in Tanzania. She has an extensive research profile with the theme on the global Children's non communicable disease, and she's the director of the global Surgery course for Oxford University. She co represents Oxford University for global surgery. She's the chair of the International four, um, for the British Association of Pediatric Surgeons, and she has links with pediatric surgery through Tanzania Bangladesh and South Africa. She is the immediate past president of the Global Initiative for Children's Surgery, and that has followed on from the Lancet commission. And she's editor of six books, and she is the author of Over 350 pair Reviewed publications. So we're very excited to hear from her today, thank you very much. And it's a great privilege for me to be sharing this platform with the audience. Uh, it's lovely to see so many up and coming people who will be able to take global surgery. Uh, anesthesia and obstetrics further. Uh, there's a slight leg and just trying to move my slides. Thank you. All right, So, uh, you know, it's a surgical community which includes our anesthetics and obstetrics colleagues. Uh, you know, we are due hours, but we are also thinkers and we have lots of challenges, as as the doing profession in medicine, we are busy clinical service, especially when we're working in the low and middle income countries. Uh, we are still very specialty. Despite the knowledge that we gain. We also need a skill protected time for research is a major, major issue. Uh, in l m I c s. Uh, there is a concept of surgeons scientists creeping up within the high income countries. But there is a problem with that as well. Where the surgeon scientists concept is disc killing our trainees in the skills that they wished that they need to attain during the training period. So that's just not be it's solution for research interest among our junior colleagues. Funding is the issue, and the main problem is time management. So as as a a doing profession. Doctor, how do you requip yourself for this role? Uh, the important thing is that you need to be interested in wanting to think through your problems and apply them and and and learn about them. Uh, and you know, you start off with case reports, case series audits in the earlier stages, and that is part of research. I mean, I remember very clearly working on a case report with my L. M I C colleagues, and it took 14 revisions, but I was very clear that if I just wrote it, there was no learning process taking place here, and the learning process can be hard and grueling, but it has to be done because once it's done, it's a no brainer. Uh, they're systematic reviews. One can do, join anaemic program, uh, and then take on further research into studying for an M S C or a default. And And the studies can be local, regional national international studies. And you know the interest is wide. You can do wet, wet lab work sort of working in the laboratory, or you can do dry lab work, such as looking at systems and looking at countries and looking at, uh, resources and so forth. But the game changer in, in a busy doing profession is a med. So when I was asked to support my colleagues in South Africa to develop the research program in pediatric surgery, uh, the way we did it was that we introduced the, um, med concept, which is part of the university scheme. And we made sure that every S p r, uh in the Department of pediatric surgery after having a research baseline study module that we ran has to enroll for an M it otherwise they do not qualify with the fellowship in pediatric surgery, and this enforced people to start looking at research within the work time and and it brought up about a huge success that within five years we have about four people within the pediatric surgery department working as surgeons but also taking on a PhD program or MSC programs. So it's quite a big game changer. And as our American colleagues always say, if not written, it never happened. So how did I develop research in a low income country? So I started off working with my colleagues by invitation in Tanzania. So 22 years ago, I was asked to develop pediatric surgery in Tanzania, and this was the time when I had a job in Oxford in a bit in South Africa and I had two Children under five years of age. I was, you know, fully fledged, clinician. And how do you train people in another country when you're trying to hold things together, wherever you are? And I thought about it, and one of the things that we did is that general surgeons are fortified qualified surgeons. So what I did is I took two weeks off my leave. I took my and you leave on my own expense and started working with my adult surgery colleagues in one institution, and over the years, as we sort of started progressing with certain specific Children's conditions, we have about 17 pediatric surgeons in transit now. And in the initial stages. We also embraced our pediatric colleagues to help look after the patients. So there was a joint win win situation where the adult surgeons were kind of moving over towards pediatric surgery. And the pediatricians will get a huge input from surgeons for the patients that needed surgical input. So this concept of this model worked, and it got stronger and stronger over the 22 years in that they are now very independent. They building towards running 10 centers of pediatric surgeon, the country with hopefully about 55 to 60 pediatric surgeons in about four years time. So how do you, uh, you know, develop research in this kind of setting where people are beginning to just learn the specialty, uh, skill themselves, try and get resources and, uh, still want to look at the subject matter that they are interested in. And what I did in Tanzania is by chance, I found a public health colleague was coming to collect data from theater computers looking at how many Children were being operated on for their particular statistics. And I kind of enticed him into joining the department of pediatric surgery, working with pediatric surgeons to develop research skills and understand research mechanisms and developed research in the department. And that was a game changer as well. So, you know, the clinician's and the public health colleagues there, too now work together. Uh, they work on the publications together, the ideas come together. And now we have a research program running in Muhimbili Hospital, uh, lead locally by local resource researchers and working hand in hand with the clinician. So the leadership is run by, uh, research and the clinician working together. And the one is so interdependent on the other that they cannot work independently. What have we done recently? Uh, the current projects we ran was looking. We did our CT randomized controlled trial on surgical site infection in Children. Uh, we looked at access to safe surgery. How do patients rich tertiary levels centers for the Children's complex surgery, And we did some work on a perioperative booklet knowing that the whole checklist wasn't working. Uh, so on the soap study, as I call it. Uh, what we did is we gave a group of patients that come to theater just come in the way they normally do. Either they have a car accident, bath or better in bath, or some of them didn't have anything. And then the intervention are. We gave them just soap from the community, which was which day you didn't have any antibiotic properties. Just water. We taught them up. This how to watch the Children the day before surgery and wipe them down with a dry towel and also concentrate on areas such as the axilla, the nasal behind the ears. And in this trial, within, within a short space of time, we had 80% reduction and the research committee, the ethics Committee, came back to us and said, Look, we need to stop the trial because the intervention arm is proving to be so productive. And this this work is going to be published in the Journal of Pediatric Surgery and one the first prize at an international meeting in July. Similarly, we looked at how how do our patients come to the tertiary level? Where were they coming from? And what we found that our patients were out of pocket by $69 for every patient that they brought to the hospital. And by doing this kind of work together as clinicians and and, uh, public health workers, we approach the government to up. So the government in Tanzania does provide free, free care surgical care for Children under 10 years of age, uh, and provide some sort of insurance when they reach the hospital. But anything outside of the hospital is not covered. And this paper pushed the government to change that and support families whose Children needed surgical intervention. Knowing that the good safety checklist was not working because it was a foreign, uh, foreign project brought down into the area, which had a different way of working together with the whole theater group of people such as the porters, the nurses from the ward's, the nurses in theater, the any theaters, um, the coordinators and so forth. We have created a booklet for every patient that from the time they leave the war for the theater, the checklist from the word is done by the nursing staff. That booklet is given to the porter, who then kicks off where he's taking the patient and then in theater. You know, there are different groups of people, but all the documentation is in one booklet, and where we are with this is that we read a pilot study which showed that there was 93% acceptance by everybody because they were party to designing this booklet, not being given a checklist that is created by somebody else. This was their own product that they put together, And, uh, and that's why the acceptance rate is so high. And at the moment the booklet has to go through the hospital printing. You know, you've got several bodies that has to approve that. This should be printed an official paper before it is rolled out. It's a bit stuck in in in one of the administrators office. Uh, so in in our group, we've also looked at, you know, low cost stoma stimulators. So you know, we've taken a little box of plastic box and put some pig skin over it to to do simulation models were doing point of care ultrasound for the surgical community to avoid diagnostic problems in that, like if a child has got a abdominal, abdominal pain or something, slightly unhappy in the abdomen. Then the surgical registrar could put the ultrasound and decide whether to refer the child to a tertiary center or deal with the child locally. So it just saving a lot of point of care problems. So, uh, in Oxford, I formed the Global Children's Non Communicable Disease Group and we looked at, you know, we're going to look at three different areas, uh, looking at, uh, cancers. So when the pandemic hit, there was lots of, uh, difficulties with Children who are partly on cancer treatment and Children who needed cancer treatment. So, um, I approached my my colleagues around the world to say, Why don't we do this, uh, looking at the impact of cove in 19 on our Children with cancers and because we were all committed people. We have no funding for this project. So we started the project within two weeks. We had about 100 countries sign up for us, and we do this. And you know, a large community of medical students and a large community of doctors were left without things to do, and they all came in. They all came into the fold of wanting to do this because they realized it was so community based. And what we found is that you know, if you were born in an l. M. I see you have a 44 chance of dying from cancer, Uh, at 30 and 90 days and at one at 12 months. Uh, the death is related to income Group A, say grade of anesthesia and the tumor type. Um, and we've had three publications from this. All of them have gone into the BMJ through the group, so there's no such thing as first author and last author. Everyone is inclusive on the same path. And even on this one, we won first prize presented by our air my colleagues. So all these papers that have mainly basis in L. M. I see the the primary persons that we work together with on the corresponding author lists or the first leadership of the group of people that are working together on an equitable scale. And that's why it became quite, uh, you know, encouraging that, uh, studies like this that are very inclusive are getting attention and winning prices for the right reasons. Uh, other things that can be due to have a very good relationship. And as I said, part of my work is in Johannesburg, at the University of Water Run and with my counterpart there, uh, Daddy Harrison, whose face you see about the the end below. You see the public health worker. We are doing quite a few studies with our med students, and this is the thing of working together with other departments that have access to lots of research platforms. So it makes it easier for us, which are the doing professions. I work very closely in the Global Initiative for Children's surgery, which is a platform for anybody that has inclination towards Children surgery. We form a nurse's group, and the nurses groups are leading a study on wound, uh, an infant care, which is of their choice. And they're getting many, many countries involved to roll out their study. So at the moment they have received, uh, ethics from almost 90% of the country's that are involved. Bar, too. We're also looking at trauma prevention in Zimbabwe. So our Zimbabwe colleagues came to us came to me in Oxford to say that the incidence of child trauma in Zimbabwe has not decreased compared to the rest of, uh, the Southern, uh, rest of sub Saharan Africa, and it's very worrying that a smaller country like that is having such trauma death rates for So we're going to We are busy now developing form a prevention program with Professor Gouty who's on the bottom of the screen, who's in the leadership in Zimbabwe for surgery and at the top. You see Simon, who is a colleague from South Polar in Brazil who did a similar study in her region and reduce the death rate over a period of time from 6000 deaths per year to 3000 deaths, and that is amazing what she could do. So we're using her platform and learning from her to do the similar study, uh, and prevent trauma death in Zimbabwe in terms of birth defects, which is the third theme of my research platform. We're working with our Bangladesh colleagues to inculcate the idea that if you are born with a birth defect, you're not a monster and that a lot of the birth defects at birth can be changed, can be cured and Children can have a better life. So we're going to do a community based program mainly change mindset of doctors, nurses, junior doctors, clinicians and the community, and understanding that that birth defects is part of a medical stream. And these babies should not be thrown into the river or should not be kept hidden but have a role in the community as well. And a lot of them can be treated. We're also aware that a lot of Children's surgery is being done in the district. General hospitals buy adult surgeons because Children cannot reach uh, you know, the tertiary center for families cannot reach tertiary centers for mere financial purposes. So, together with my colleague in India, uh, Professor rhythm a jury, uh, we decided to develop a south to south training program knowing that if we designed this program in Oxford or in the States or in London, uh, it will be not fit for purpose. So, together with an L M I C. Country, we designed a program that was mainly ideas that came from the ground, and we formed a training team, uh, 2 to 3 Children surgery, uh, in the team. We included a theater nurse award, nurse anesthetist, orthopedic surgeon and general surgeon and we ran three pilot courses and hopefully in February, we're going to start our first Africa based course Where the team from Africa Uh three pediatric. You know, seven pediatric surgical teams from seven. Uh huh. Trees are going to come to the law to be trained as trainers, to take this back to the relevant countries to then run this program with the District General hospitals too upscale their skills. In Children's surgery, we wrote the concept up which is in print, and then there are other groups of people that come who are wanting to do research. Uh, and this is a colleague who is an F one, which is a house officer first just out of medical school, and have taken on what we call in the UK in AFP, which is an academic foundation program. So what happens to the AFP is they are given in the day in the week or a month in three months or a week in three months or something like that to do research work. And this particular F once, uh, kind of ancestry comes from Bangladesh, and, uh, my colleague in Bangladesh, who you saw earlier I was really worried about transfusion problems in Bangladesh. So together with, uh so me, who is the F one? We did some work in Bangladesh together with the counterpart, a similar trainee, uh, in Bangladesh. And you might recognize Sarah Davidson's name, who was also part of this project with me who's known to guess, uh, in in very fondly. So Sarah worked with us and we did the first phase where we did a systematic review. Uh, and then the second phase we looked at transfusion practices and we're just completing the first phase. And in the world that we're doing, I find that I would not take on work which is not impactful, and we realized by just doing the phase one Phase two, we have been saving $3 million for transfusion in the six months and this is just, uh, you know, quite mind boggling that how Just by doing some simple work, uh, which is led locally from the ground, you can make such huge changes. Uh, similarly, a colleague wanted to do some work in, uh, AFP similarly wanted to do some work in Kenya, and I approach a colleague who was very much involved with the canyon team to say, You know, there's a AFP Why don't we look at uh, the Children's surgery that has been done in District General hospitals? Or how much of the surgery has been done outside of the tertiary hospitals and the team came back to us and they said, No, no, no, that that's not what we want to look at. We want to look at neonatal pain, and that's how we work. This is what the ask was, and this is what we did. So in working with the team and kind of just helping them with what the ideas were and what the concepts were, were able to develop a national guidelines for neonatal pain. And we simplified it that you don't need more than just these four things to control neonatal pain, breast milk and sugar for minor procedures, paracetamol for intermediate procedures and morphine for more complex procedures. And the cost reduction by just having the simple national guidelines, was 65% for the national budget for pain relief in babies. We also had an F two who wanted to look at some work because he his career aspirations and you probably many of you know, so, um, his career aspirations or to become a neurosurgeon And we looked at a traumatic brain injury. And this also made a huge change in how we would be dealing with your disability by having the data from this particular publication. And and there's lots more that we've worked with. And one of the things that I'm really proud of is that developing ox floor now explore stands for Oxford Pediatrics linking our research with electives. Lots of Oxford students go to L. M I. C s for their, um, electives. And what I said to them that why you're going there, why don't you use your time more useful and and do something while you did such? And I'm very happy to give you a project. So what I did is I matched every, uh, every Oxford student to the site that he's going. He needed to find a counterpart there like a pimple, and I gave them a topic each for the first three years to work on. So people went to about 20 different countries and they had the same thing to work on. And within three years, we had all the publications that they put together because it was so locally intensive and locally guided. They were prize winning the concept one, the price of the media periodic meeting. And, uh, all of them have gone into a high impact journals. And after three years, the rest of the time, the topics are no longer dictated by me, but our decided by the local teams as to what they want to study. So ox Flow is actually formed a group to then decide on topics and work together during the electors. And these are some of the prices that I was talking about. These are the different phases that we went through and then coming to Children's needs. You know, in most countries, in especially in my country, in most element countries, I correct myself. Up to 50% of the people are Children, and almost, uh, two thirds of Children around the world don't have access to surgery. And, as you know, 85% of Children will require surgical procedure before the 18th birthday. Be the tooth extraction because that is also a surgical procedure, you know, and surgery is not expensive. You know, HIV treatment for life, for 11 year old boy or a girl will cost 300,000 lbs for that person's life. Inguinal hernia repair cost $50 and that person can be economically very, very contributing to to the country. Gigs is an organization that looks after Children surgery. It embraces all Children's surgical carriers. It's a joint venture between L. M I, C and H I C, with emphasis on mainly l m i C leadership. The vision is to have safe, affordable and timely surgical care for all Children. Uh, the first thing we did is an organization. When we formed in 2016 is to develop a standard optimal resource document, which is a standard setting document for anybody and everybody who wants to do Children's surgical services. Be a nurse physio, uh, clinical officer, A doctor, uh, administrator, the government, they are standard settings in that If if I mean the government decides, Look, we want to put up the Children's hospital, Uh, in in this particular country, the standard is in this document. So, uh, we're also I'm also involved with, uh, kind of developing global surgery at Oxford University. Uh, as a group, we've what I felt is that. I mean, I know it's become fashionable in H I. C is to have a global surgery as part of the group in a very kind of, uh, a kind of patronizing way. But what we did is that in Oxford we decided that we're going to have a four departmental group. So our global surgery group has, uh, women's reproductive health orthopedic surgery, uh, the anesthetic group and surgeons, all four departments working together as a global surgery group. We have medical students with us. We have themes. We have MSC PhD students at the moment. You know, I have about seven post graduate students doing PhDs m s m. S C. S. We done a course that is open to almost, uh, anybody that has an interest in global surgery. It's a one week close that gives you 20 cat points, and we hope to develop that into a masters. We have, uh, salami maximum. Who's a very good friend of mine in you. CT. We have joined a PhD students, uh, MMSC students. I have, uh, work with a colleague. Nobody. Troy in India, where we're looking at a rural surgeons and and their needs and there's lots of work's been done because I'm part of the university of that restaurant in Johannesburg. What I'd like to say is that, you know, in global surgery, the most important thing that we can work on now is equity. Uh, I love this slide given to me by the person who actually started up gas. Uh, my dear friend Newell, Peter's showed me the slide, and I just find it brilliant to to conclude my talks with it where in reality, you have some people with lots of resources and others with nothing. And we always think that if we throw the equal amount of resources to the needy, then the problem will be solved. But equality doesn't work because some people are starting at a very, very lower level. Uh, in terms of resources, equity is the way to go where everybody is, given what they need and what they deserve so that we can read justice, uh, in in a very short space of time. Hopefully thank you for your attention. And thank you so much for that really fascinating talk in all your experiences. And towards the end of the session after we've had our second talk well, then move onto questions for both speakers, so please be putting them in the chat. Um, our next speaker is Doctor Michelle Joseph. She's an orthopedic trauma surgeon specializing in trauma systems and health equity research in Haiti. Gardener in the USA She's an instructor of global health and social medicine at Harvard, as well as being an associate professor and in the department of Surgery at Walter Reed, an Ortho Plastics trauma fellow at Brigham and Women's Hospital and a research scholar and chief and strategy in health equity officer. The program. In global surgery and Social change, she leaves a body of research, which is related to epidemiology, quality, improvement, implementation, science and innovation. Her commitment to social justice and health equity education is demonstrated by her leadership in the development and implementation of an anti racism curriculum and the anti racism curriculum for surgical residents. For the Harvard affiliated surgery programs, she's got extensive experience, and she'll be talking to us about the challenges, um, equity in global health research. So we'll have her first, and then we'll have a time for questions at the end. Thank you. Thank you. Um, it's a real pleasure to be here and thank you for participating on on the weekend. I I first want to Really? Thank you, Professor. So many of the points that you made. I had to write some of the notes down because they are so relevant to the talk I'm about to give in terms of asking local people what the needs are and then having the power and be able to set the agenda to determine impact is really key. You talked about the bidirectional learning that occurred as well as how to implement effectively things like the checklist. The wh Oh, we're not working well. And therefore, needing to cry, create one in country by those who will be utilizing and having a 93% acceptance rate. There are real lessons there in the principles of research justice, but also health, justice and you mentioned at the end, which is a beautiful Segway to my talk in terms of what justice and equity actually looked like in the space of healthcare delivery. But in the research that we do, I could go on on on on on on your talk, because it was so fantastic. I thank you. Uh, for that. And I really want, uh, the audience now to remember all that was said in the first talk and understand the principles that we're using is the principal that I'm going to talk about when I go through my slides. Now. So at the center, at the core, the cornerstone of the work that we do in research in global surgery is health equity. That is what we are striving for. That ability to create new or increase the existing opportunities that allow for healthcare delivery to those that need it. Which is all of us in an effective way is how we established the true equity and is what leads to the justice. But how do we get there as researchers? So I'm going to take you through some of the high level principles around establishing this. What are the pillars that support this cornerstone and examples of what it looks like from a high income setting standpoint, research standpoint, and also what it looks like for all researchers, irrespective of where you're from. And I have to say a lot of this has been adapted from a framework that I really appreciate. I think we all should read it and try and emulate. It's written by uh Pratt in BMJ Global Health and it's Research for Health Justice. So when I think about the four pillars and something that's really described well, we think about the population, which we are trying to serve and research. We also think about the topic and the question and who's setting those agendas. And we also think about the capacity to develop with all of these things. And, you know, this conference is about the sustainability. How do we create sustainability in this work? It's by building capacity and capacity independence in that space. And how do we perform the act of knowledge translation that can lead to transformation in healthcare delivery? There are a number of components that we will now go through. Let's start with research population from an H. I. C. Researchers Perspective. The things that we really look for and try to attain is identifying partnerships and partnerships that can really govern how we do the work and also can tell us where what is needed. Where are the most significant disparities and how, how are those identified and for researchers, what we really want to strive for is making that impact that we heard about in the previous talk. How do you get there? We get there by understanding what community needs are and what the priorities are. Yeah, To understand those priorities, we have to understand what the baseline is. So part of your questioning when you're interested in a certain population that you desire to research is what is the current status now and where are the gaps? What are the immediate needs? And where are the areas where you can make the most gains that are most relevant deemed by those who experienced this on a day to day basis? I those who live and work in this space. We also think about the actual community. And when we're setting our research questions based on the population, we really need to try and identify. Is this going to impact a large number of individuals? Or is it for a few now, depending on the type of question and the methodology that you're seeking to use and the scalability of the problem or the solution? Rather, the intervention generalize ability is key when you're trying to mitigate those gaps when you're trying to reduce health disparities. And also we want to ensure that when we're looking at communities, we are looking at the entire picture and not adversely doing harm because of our short sightedness. And for all researchers, there is a real need for there to be guidance in the space that allows us to perform this as as an inclusive process rather than one that inadvertently in excludes individuals because of potential time pressures. And this is how, when we think about the topics that we that we choose, or rather than, uh, opposed to us as the priorities, we have to think about it through the lens of equity. And what does that actually look like when building our questions? So we talked about talked about priority setting, and there are three key areas that we need to think about and that really comes down to who are stakeholders are who are your local leadership in the country's in which you want to work, or the country that you want to work or even the community you want to work. Who actually exists in this space, the community and who in the community has a voice to assist, assert, give you, um, the knowledge that you need in order to work in a partnership to design effective questions that should be researched. And finally, who are the participants in this space? It's important to understand all of these three stakeholders because ultimately they all should play a part in the development process. Yes, when we think about the priority setting, there's some level of, um, how you approach it and how your organization or your team approach. Is it that matters? One thing I always come back to is who holds the power and who gets to make the decisions. And is that decision maker making equitable choices? One way to ensure that this happens is that before you even develop a question before you start to think about what the priorities, maybe you approach it with an enquiring mind and try and develop this alongside your partnership that you choose to develop. This will involve the conceptualization, which can take some time, a planning, which means there may be some back and forth and in determining what is needed. But also it requires you having an understanding of what literature currently exists in that space, where you can contribute in an effective way, but also understand that the priority setting has to lie with those who work within the space when you're organizing your team that you're working with, it's also key that your collaborators come from the different areas of the stakeholder groups that I mentioned, sometimes challenging to have the participants who are often the recipient of the care delivery as part of the research group, if you like. But at all times we aim to really include their voices in this space and build what we call community partnerships. But partnerships with community individuals who will be recipients of the care delivery that you seek to, uh, perform as a as A as an intervention, so a bit more on the actual setting in which the research will take place. Health systems research is key, so understanding where the intervention will be implemented, there is an understanding of how the health system works in that environment that is important to really help you determine the logistics but also the feasibility and without having an understanding of the system. And this information is really informed by the people you work with. It is challenging to to set a a useful, um, and effective plan. This understanding does not exist, by the way. Please do not take notes for this. All these slides will be available to you. They are text heavy for a reason because I want you to go back and actually reflect on various principles that are involved in each stage of development. So when it comes to research capacity building, what we seek is to create that level of independence. And you heard in the previous talk about developing these, um, teaching how the the the education component to this and how we there is a shift in autonomy from those who are, uh, being recipients to those who are then governing what actually happens and what research and how to conduct and being able to do so independently, but also forming the collaborative as well. And there are a number of different methods. The one that we heard of in the previous talk was that south to south collaboration and the strength in developing that. Either way, there are different mechanisms to developing, um, research, independence and capacity independence and at all times, we may we must choose to, uh, work to overcome the barriers in order to really strengthen these relationships, but also to prioritize the sustainability and sustainability comes from when knowledge is shared and knowledge is, um, knowledge. Literacy is appreciated. Well, come on to the literacy component in a moment. In addition to the independence that we speak of, we think about ourselves, uh, as individuals, but also as part of the team and also part of an institution. We have different methods to get there, and again we had in the previous talk about There are various degrees one could do to help you acquire the skills in order to work effectively in the space. There are opportunities to apply for grants, but also there's a skillset that is required in order to apply for grants effectively as senior research. As we move into that, P I stage of being principal investigators on different areas of study or inquiry. And how do we really try and develop those long term partnerships in a responsible manner? Or it comes from having a good baseline set of skills, but also understanding the equity and justice component when you are developing these projects in terms of the institutions that we work for there are various infrastructures that need to be in place in order to support this, work carefully and not do harm things like managing grants effectively the technical support that is required, uh, the education that can be, um, imparted that knowledge translation that we seek. And finally, when we talk about the impact that we want and how to create change, being able to have risk that that leads to policy change is highly effective. And we have many examples in the previous talk about how, um, they were able to create a significant change by raising awareness through creating data evidence. And I think it's important to really look at how, even at a junior stage, the one who was in the academic position was able to publish in The Lancet child and adolescent health, a very pivotal, um, piece of work that could potentially lead to a policy change. Looking developments in effectiveness is really key, key strategy to take and with all things impact, we should aim for it to be lasting and fleeting. There is a challenge when we were unsure research positions needing having that need to to, um develop and create and publish may not always coincide with the impact that really is just thing to do, and it really is a thing that leads to sustainability. So we've spoken a bit about all of these factors in terms of who sets the questions, how we actually go on to execute it, having our partners in place, working with community, working with participants, recipients, care how we perform sustainability when it comes to senior researchers and institutional responsibility. I think it's also important for us to think about this in terms of our own individual responsibility in this space and making sure that we are developing things that are feasible but also are needed. So if we look at this framework again, but through the lens of how do we apply it? And we think about the application at the three levels I mentioned the individual level, the team level and the organizational level, and there are some questions that we need to ask ourselves in order to ensure that we are not doing harm but pushing the equity and justice agenda when it comes to performing meaningful impactful research that is sustainable in building capacity and creating change as an individual with a new project. Questions I always ask myself is, Who's established the needle? Is there a need and what is actually already being done in that space? Having that place of inquiry is important within your team. Do we have the skill sets to be able to deliver? Do we have the skill set to actually work effectively with this with a partnership with in a partnership? Are we offering something that we are unable to do? Are we overreaching? Are we over promising? And what is the long term vision? What is the long term goal? And within our organization, do we have sufficient faculty support? Are we able to be effective in taking this through to the end point and what happens after the end goal is reached? Where does the partnership go from then on? In terms of the setting? The question. It's important, especially when you come from institutions like Oxford and Harvard. There is a real sense of hierarchy, the takes, its place in the room, that when you come from these kind of institutions and it's important to try and dismantle, and I say that because often when you're working with a group initially that may not have the research capacity. There is a higher level of literacy that is, that we frame as the lived experience that is important. And if you are unable to give that enough, um, airtime or value, then you will always be seen as coming from this higher institute that has the prestige and therefore a seeming knowingness. That may not necessarily be true. And every point in your interactions is key that you really try and push back on that and ensure that your partners are setting the priorities and that you are attempting to build capacity and that the governance, irrespective of the research literacy, should lie with those who are in country. And if it is your l I C. Uh, partners, then it has to live with them. It has to be within the setting. They have to be setting the agenda. And again, this is true for the capacity development. Often we think about, um, power and who holds the who holds the funding. The funding is often tied to HIV CS, but there is a real shift in terms of how this funding is distributed and who has who gets to apply, and the criteria for applying is shifting, whereby the partnership aspect, the equitable partnership and the by directionality of it is really being built into some of these grant processes. And I think that's really important when it comes to developing that transition of knowledge and the transition of power that needs to happen in order for, um, ask too correct the imbalance that has played out in legacy between H. I C and L M I C. Research building. When we think about the translation and apply the framework to us and our teams and organizations, we have to always think about accountability. What is our responsibility in this space? If we are performing research and we hope that there will be some knowledge transfer, we also have to think about the potential for transformation and the extent to which that can play out. Following up on the work that we do is really important in establishing that. Have we actually made a difference? Measuring the impact is key, without knowing whether the work that we've done has any form of sustainability, Uh, for short of us doing good work for short of following the principles of health justice. If our aim is to truly make a difference in the spaces in which we work and who we collaborate with, then we have to take into account that we must monitor what we do and the impact that it has and stay accountable to the choices that we we make. So in summary, when we think about, uh, research be at all three levels, we really want to avoid exploitation and perpetuating injustices that do exist. We have to remain inclusive and make sure the decision making is held in the balance of those who we work with. Our partners in the l M O. C. Setting and at all times and with all things we want to embark on developing and holding true the want to produce capacity independence in institutions and researchers that exist in the low and middle income um, settings. And with that, I thank you for listening, and we're happy to take questions. I will stop sharing my slides now. Great. Thank you so much for a fantastic talk. And we have to brief questions, if that's okay. Um, So the first question is, um, for myself. And I was just wondering what are some red flags to look for. If you're getting involved in a project to see if this project is to H i C heavy and to kind of warning signs that it's not an equitable project that you're participating in. I know you've got a head. Do you want to answer this before you leave us? I think the important thing is that the project doesn't belong to you. The important it is, uh, you know, why do you need a program to take out there to say Okay, this is what we want to study. The important bit is collaborating with your colleagues engaging with them and say, Okay, what are the problems? What are the needs? What would you like to do? What is really the burning question with you? And that's that's where it starts because anything that you go with an idea for which you think might be what they need in a very funny way as to what do you need? It will never work because it's your idea from a space that is very different from the space that your colleague out there is. And therefore I feel very comfortable in my research that every project that I've done is locally lead. And, uh, you know, it's locally designed. I'm just the catalyst. I go there and provide the support and the direction and maybe a few new answers to to, you know, tweak it here or tweak it there. But the first author that, uh, you know, corresponding author everything comes from the ground, and that's that's how you develop research because it's from within rather than from without. Yeah, I completely agree with that. I think many red flags for me already mentioned. But I would stress that the project design Who the who the PPI is. Is there a copay I that is in country, Um, who the first author is and who the last author is on the paper and how data was collected. Who said the agenda The red flags for me when all of those things lie within HIV researchers and not from L M I. C. S at all that is highly problematic. Uh, there's some work has been written by Dr Bethany Head GTO. I would encourage you to look it up and read it. One of the pivotal paper's stuck in the middle, which demonstrates a number of the authorship essentially and where who where the research is from and where the authors are. There is a There is disparity there. So when I see things like that, it's discouraging because I don't think that's how we build capacity. I don't think the intention there is to shift any form of power towards those in l m I. C is, but rather it's to continue holding it. Thank you. We've got another question. Um, from Holly on the chat, he says I'm sometimes ask for advice on research projects. My colleagues in L M I. C. S. Are there any good online educational resources and practical approach is to conducting research you would recommend which I could share with them. So just repeat that Bill, Are there any good resources for people who want to conduct research in L. M I C s? Yes, that was correct. I can't hear you. You're speaking. Thank you. So in terms of good resource is the one I just mentioned as Bethany had a UTI, and I'm happy to send over some of those references to read the how to. Uh, it's a fantastic op ed. That's been written by a satirical in nature by, uh, Desmond, just, um uh, echo in BMJ Global Health. How not to do, uh, Global Health Research, Global surgery research. I'm happy to share those. I think it gives you very clear guidance as to how not to miss a step. The other thing I'd say, is the framework which I referenced in the talk. I would encourage you to read the larger paper. It's very useful, very practical. And it tells you on an individual basis what you should be doing and what you should not be doing, what to avoid. And I think it's also empowering that you can take that to your team as well. You want to make sure that with all your steps, you are making the right equitable choices and are using those three things as a reference point as your steering compass, if you like, is, um would be useful. So I'm happy to share those. Yeah, uh, we have just one more question if we have time, is that okay? Um, so the last question is just, um from the tarot Paul Steven Ella. And he mentioned that ethical clearance seems a big challenge in L. M. I. C. S And in Uganda, a research collaboration with Netherlands took over 10 months to get ethical approval in Uganda. How do we go about such or change research settings? Um, my answer to that is that is not uncommon. That's very true. It's very hard if you've only got a one year research post and you want to develop this work. And that's when your team and the organization, the institution that you work with, should step in. And I say step in in the sense not to change what's happening in country because the ethics procedure is the ethnics procedure. But to actually ensure that you are embarking on projects that they have either started that have ethical approval because practically there's no way that you would be able to embark on that work. Uh, if you are starting from scratch when the IRB process takes 10 months and you're only imposed for one year, it is not practical. That is part of the accountability factor that your faculty support should be looking at to realize that the time constraints, but also what is feasible. You you cannot change in country process unless you are in country individual yourself who resides there who wants to, uh, work with the i R B, the institutional research bodies to help with their systems. It would be a misstep if we from HIV were to go in and say You're IRB process is inappropriately long. You need to change this because you're just going to get people's backs up. I think it's important to embark on projects that have existing. I'll all start early knowing that the procedure takes 10 months. And knowing that you're going to be in that research post next year means that you start your IRB process from now. And those are the kind of logistics you have to work around rather than trying to change in country processes. Unless you reside in country yourself. That answers your question. I had a sort of paraphrased version of it because I can't hear the audio so well, Yes, that that was one was from the chat, so I think so, yes, thanks so much. Thank you so much for such excellent talks