Anne Cockcroft, MD, is a clinician and public health researcher with a background in respiratory and occupational medicine in the UK. Currently based in Botswana, she has worked with a research and training non-profit organisation, CIET (Community Information for Empowerment and Transparency) since 1994 and has undertaken large scale community-based participatory research projects in over 20 countries, primarily in southern and west Africa, south Asia and in Canada. She has studied access to and experience of health and other services by the most vulnerable, working with them and with service providers and policy makers to use evidence to develop equitable and effective services. She is a member of PRAM (Participatory Research at McGill), a research group within the Department of Family Medicine, which promotes scholarship on participatory research, offers expertise and training in participatory research, and increases community and patient engagement in all aspects of health care.
Dr. Cockcroft’s international research projects cover a range of key issues such as HIV prevention, gender violence, maternal and child health, and adolescent sexual and reproductive health. Dr. Cockcroft has trained health planners and researchers in southern Africa in evidence-based planning. She also led a project funded by the Southern Africa Development Community to train HIV researchers and health planners, in English, French and Portuguese.
Challenging your own worldview
Historically, western researchers working in low- and middle-income countries have taken a colonial approach to change behaviours or attitudes they consider incorrect. Local culture was disrespected and there was an assumption that approaches developed in high income countries would work in a different context. Problems persist today and the under-representation of researchers from the global South does not help. Researchers from high income countries still conduct the bulk of research on health and development issues in low- and middle-income countries. Nearly three-quarters of the articles published in the top 20 development journals (1990-2019) were by Northern researchers. Not only are Southern researchers published less frequently, but they are also cited less frequently, (Amarante & Zurbrigg, 2022).
In recent years, there is increasing interest in participatory research and Dr. Cockcroft and her colleagues at PRAM are leading the way in developing this field. Their goal is transformative engagement of researchers with decision makers, health care providers, patients and communities in the co-production and use of knowledge to improve health and healthcare. They provide innovative and culturally safe training to ensure the next generation of researchers is equipped to develop participatory research and knowledge translation. PRAM’s methods address priority issues in health care – respectful partnerships, intercultural dialogue, and equity-oriented research – particularly supporting those in resource-poor settings and the most marginalized.
“One way to avoid a colonial approach to research is to challenge your own worldview. Participatory research is about being prepared to listen and learn,” says Dr. Cockcroft.
In participatory research, the people affected by an issue are partners in designing, implementing, and measuring impact of interventions. There is sometimes a misconception that people’s knowledge and perceptions about an issue are not scientifically valid. Dr. Cockcroft notes that this is far from true. Participatory research uses a range of methods both quantitative (numbers) and qualitative (looking behind the numbers). Methods such as fuzzy cognitive mapping can explore locally relevant causes of health and other concerns that inform evidence-based strategies and policies. Dr. Cockcroft’s research has sometimes involved using technology innovatively for quality control. Her research in Bauchi State, Nigeria, for instance, used GPS enabled handsets for home visitors to allow robust remote monitoring and quality control. Software enhancements prevented submission of invalid records.
Turning knowledge into positive change
Some of the research carried out by Dr. Cockcroft and her colleagues has led to scale up of successful interventions initially undertaken in a research context. Dr. Cockcroft argues that decision makers need evidence to allow them to allocate funds for services that will have the most impact. One example is from Bauchi State, where maternal mortality is among the highest in the world. Dr. Cockcroft’s research team tested whether home visits with pregnant women and their spouses to share local evidence about maternal and child health risks could help households to take action to improve maternal and child health. The research included nearly 30,000 households and resulted in a 20% reduction in maternal and child morbidity.
“This study supported our conceptual framework, whereby households make changes after going through a sequence of intermediate steps, beginning with hearing about local evidence,” says Dr. Cockcroft.
The research specifically involved men, through separate visits to spouses and the results indicated that the visits changed male knowledge and attitudes. It also demonstrated that improvements in maternal and child health can be achieved through actions at the household level and that these improvements can happen even in the absence of improved access to quality health services. Evidence of the impact of home visits from the research project has led the Bauchi government to commit to rolling out the program across the whole State.
Choice Disability is a driver of the HIV epidemic
Another part of Dr. Cockcroft’s work involves HIV prevention in southern Africa and Botswana where prevalence rates among adults are among the highest worldwide. In Botswana, about one in five adults aged 15-49 years are living with HIV and most of the new infections are among young women. A study in Botswana, Namibia, and Swaziland found that young women who suffer intimate partner violence, have income disparity with their partners, have less education, or who are very poor have a much higher risk of HIV than young women who have none of these four factors. The narrative that the HIV epidemic can be halted just by education about the risks disregards the underlying causes of the problem.
“Structural factors perpetuate the HIV epidemic because they lead to choice disability, whereby people are constrained in making choices to protect themselves against HIV, even when they know the risks and how to avoid them,” says Dr. Cockcroft.
Dr. Cockcroft stresses that if choice disability could be prevented or its effects reduced, this could reduce new HIV infections, especially among young women. The Inter-ministerial National Structural Intervention Trial (INSTRUCT) is an HIV prevention initiative in Botswana that tests the impact of a package of structural interventions focused on young women and the choice disabled. The nationwide study, led by CIET and Botswana’s National AIDS Coordinating Agency (NACA), implemented the interventions in five districts across Botswana. The interventions aimed to build life skills for the young women and help them to access government support programs.
How is this work in low- and middle-income countries relevant for Canada? Dr. Cockcroft reminds us that participatory research is just as relevant in Canada as elsewhere. People everywhere can contribute their knowledge and experience to find solutions for health problems. PRAM is undertaking participatory research projects in Canada, including projects with Inuit communities in Quebec to promote cultural safety and address institutional racism.
“There’s no point doing research unless you’re trying to make a difference to people’s lives. I’m humbled by the people that I get to work with every day,” says Dr. Cockcroft.
It’s fair to say that this humble researcher is indeed making a difference in the world.
To learn more about Dr. Cockcroft’s work, please click on the following links:
