Martin, Jennifer Shona; (2020) The challenges of translating the women's group Participatory Learning and Action Cycle from multiple low-income countries to the UK NHS context, using nutrition in infants of Bangladeshi origin in Tower Hamlets as an exemplar. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background There is a need for cost-effective and adaptable health interventions to address complex issues within the UK National Health Service (NHS). Reverse innovation in public health is the process of adapting health interventions developed in low-income countries (LICs) and implementing them in high-income contexts (HICs) (1). This process is gaining traction in global health as a means of offers knowledge sharing between the global south and the global north. The adaptation of interventions from one context to another is ubiquitous and necessary, but the process is often unrecorded. There is a tension between fidelity to the intervention and adaptation to the specific needs of the target context and a heterogeneous population. In the UK, ethnic minority groups in particular experience disproportionate levels of obesity, type 2 diabetes, cardiovascular disease and micronutrient deficiencies compared with the majority White European-origin population (2), and current NHS services are unable to address the increasing rates of nutrition-related ill-health in these populations. Furthermore, there are inconsistencies in the effectiveness of NHS interventions in minority ethnic groups and there is a risk of intervention generated inequalities. Adapting interventions that have been subject to reverse innovation could increase intervention effectiveness in their new context. The aim of this thesis is to present a framework that supports the theoretical adaptation of one such intervention, the women’s group Participatory Learning and Action cycle (PLA cycle) (3) using the Nurture Early for Infant Nutrition (NEON) study (4) in the Bangladeshi population of Tower Hamlets as an exemplar. The framework is intended for multiple policy, practice and research benefits. Failing to follow a framework for implementation could lead to an unsuccessful intervention (5). Methods This thesis employed a qualitative research design across two studies: 1. The principles of how the women’s group PLA cycle was adapted in practice were captured through Study 1. This study explored the process of adaptation to the women’s group PLA cycle across the original seven cluster randomised controlled trials (RCTs) in Bangladesh, India, Nepal and Malawi through 14 key informant interviews. 2. Study 2 determined the specific contextual adaptations that could address the acceptability and feasibility to the women’s group PLA cycle through focus group discussions (FGDs) with individuals of Bangladeshi-origin from Tower Hamlets. All data were subject to the Braun and Clarke (2006) guidelines to thematic analysis (6). Results The key informant interviews generated data that resulted in an outline of a generic theoretical adaptation framework. The framework includes components requiring fidelity and those requiring subtle adaptations. The four-stage framework detailed a preparation phase, the process of adaptations and highlighted a specific set of micro-adaptations that can be adjusted to emulate local context. The FGDs aimed to address the micro-adaptations that were suggested by the key informants. They showed a paradoxical relationship between the participants’ Bangladeshi heritage and their lived environment. There were specific differences between individuals who had been in the country for less than three years, those that had been in the country for more than three years, and those that had been born in the UK but whose parents were from Bangladesh. Discussion The women’s group PLA theoretical adaptation framework is the first attempt to create a formal adaptation structure for the PLA cycle which is also relevant to other participatory intervention paradigms. The framework was developed in the context of a wider study about reverse innovation of the women’s group PLA cycle model but would also be relevant to any situation where a participatory intervention is being adapted. Relatively few studies have previously considered the macro policy and political context as a influencers on adaptation processes for health interventions, although this is well characterised in implementation literature (7). Recognising the inherent differences within the Bangladeshi population of Tower Hamlets could allow the women’s group PLA cycle to be adapted appropriately by the NEON study. I believe it is important to adjust the micro-adaptations to encompass both areas of the population’s identity - heritage and environment. This has implications for other interventions that are looking to culturally adapt their interventions for minority populations in the UK. Conclusion The theoretical adaptation framework for the women’s group PLA cycle is new to the innovation literature, because they outline areas to consider when an intervention developed in a LIC is undergoing reverse innovation. Strength lies in the homogeneity of experience of the key informants, meaning that data had less ‘noise’ in terms of the actual intervention itself. This thesis has constructed a theoretical framework that could potentially assist other researchers with the adaptation of the model into their HIC context.

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