Acta Tropica, 57 (1994) 175-184 175 © 1994 Elsevier Science B.V. All rights reserved 0001-706X/94/$07.00

ACTROP 00390

Promoting interdisciplinary collaboration in health research in developing countries: lessons from the

Triangle Programme in Sri Lanka

K a l i n g a T u d o r Silva 1'*, R u u d Pee te rs 2, J u d y Lewis 3

aDepartment of Sociology, University of Peradeniya, Peradineya, Sri Lanka, ZUniversity of Antwerp, Antwerp, Belgium, 3University of Connecticut, Farmington, CT, USA

The Triangle Programme (1989-1992) aimed at strengthening the institutional capacity for health social science research and intervention in Sri Lanka through the promotion of appropriate international and national partnerships. First, it involved an international partnership (Triangle 1 ) among two universities in the developed world, i.c. University of Antwerp in Belgium and the University of Connecticut in the USA, and one university in the developing world, i.c. the University of Peradeniya, Sri Lanka. This partnership facilitated the transfer of knowledge, experience, skills across national boundaries and the North/South divide. Second, it developed a national/local partnership (Triangle 2) among the Faculties of Arts, Agriculture and Medicine at the University of Peradeniya by involving them in a joint programme of health social science research and training covering the entire range of activities from proposal develop- ment to dissemination of research results. Focusing on the latter aspect (Triangle 2) this paper reviews the results of the programme from the angle of cross-fertilization of disciplines through their collaboration in applied health research in a developing country setting.

Key words: Capacity building; Sri Lanka; Health social sciences; Transdisciplinary

Introduction

Strengthening health social science capacities in developing countries has received considerable attention in recent years. Trostle (1992), for instance, viewed capacity building in health social sciences as a developmental goal closely connected with fostering suitable institutions, developing required human resources and building the infrastructure needed for applied research in the relevant fields. He noted that 'a sustained research programme requires not only funding opportunities, but also a network of colleagues, a career path, a set of personal and financial incentives, and a commitment by the state to support or at least tolerate research as a legitimate and valued endeavor'.

With the backing of international funding agencies social scientists have developed a variety of programmes for short-term training in health social science research methodology primarily for the benefit of health professionals working in community settings in developing countries. Such training is expected to help the health profes- sionals to develop intervention programmes which 'fit more closely with people's

*Corresponding author.

SSDI 0001-706X(94)00025-V

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cultural beliefs and practices' (Pelto and Pelto, 1991). The effect of what Vlassoff and Manderson (1994) describe as 'short-circuiting' of social science education for the purpose of harnessing social science knowledge and techniques in health research and interventions has been varied, but it is clear that the role of social sciences is expanding in a variety of priority health areas including control of tropical disease (Rosenfield, 1992), diarrheal disease (Trostle and Simon, 1992) and AIDS (Schensul, 1993).

There are different models for collaborations between biomedicine and social sciences. Rosenfield (1992) identified three models which she described as multi- disciplinary, interdisciplinary and transdisciplinary. In the multidisciplinary model researchers in different disciplines work separately on a common problem exchanging their views where necessary. In the interdisciplinary model researchers in different disciplines work together on a common problem without necessarily trying to over- come their disciplinary biases. In the transdisciplinary model researchers in different disciplines work together on a common problem and seek to develop a shared conceptual framework and overcome limitations of the respective disciplines in the process. According to Rosenfield, the transdisciplinary model offers the highest potential for both theoretical advancement and successful practical application of science in health, agriculture and other areas. She argued:

'To achieve the level of conceptual and practical progress needed to improve human health, collaborative research must transcend individual disciplinary perspectives and develop a new process of collaboration...While the disciplinary basis must be the natural starting point for each team member, the starting point rapidly becomes the limiting factor in problem definition, collection and analysis of data, and interpretation of findings. Each team member needs to become sufficiently familiar with the concepts and approaches of his and her colleagues as to blur the disciplinary bounds and enable the team to focus on the problem as part of broader phenomena: as this happens discipline authorization fades in importance, and the problem and its context guide an appropriately broader and deeper analysis.'

Following Rosenfield and others this paper explores the potential for collaborative health research in a developing country setting. It reviews the results of the Triangle Programme in Sri Lanka from the angle of promoting interdisciplinary collaboration among university-based researchers drawn from different disciplines. It expands previous accounts of the Triangle Programme (Lewis et al., 1991; Rosenfield, 1992; Pelto and Pelto, 1992; Silva et al., 1992) by (a) elaborating the scope for, and constraints to, transdisciplinary approach to health in the relevant developing coun- try setting; (b) evaluating project outcomes in respect to capacity building in the area of collaborative health research; and, (c) examining the responses to the programme on the part of participants from Sri Lanka.

The Triangle Programme in Sri Lanka

The Triangle Programme (1989-1992) aimed at strengthening institutional capability for health social science research and intervention in Sri Lanka through the collabo- ration of the University of Antwerp (Belgium), University of Peradeniya (Sri Lanka) and the University of Connecticut (USA). The programme involved a triangular partnership among two universities in the developed world and one university in Sri

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International Triangle Local Triangle

Fig. 1. Collaborative linkages under the Triangle program.

Lanka. Within the University of Peradeniya, the primary locus of institutional capability building under this programme, it sought to promote collaboration among the Faculties of Arts, Medicine and Agriculture through development of a core of common interest in health social sciences. Thus the programme involved two inter- acting triangles one international and the other local as depicted in Fig. 1.

The Triangle Programme developed from nearly a decade of interaction between the University of Peradeniya (UP) and the University of Connecticut. Under the sponsorship of the WHO (MCH division) and USIA the two universities had a programme of faculty and student exchange from 1983 to 1988. As an outcome of these developments a group of medical and social scientists at the UP formed the Center for Intersectoral Community Health Studies (CICHS) under the leadership of Dr H.A. Aponso, Professor of Pediatrics at the UP. In 1987 through the initiative of a University of Connecticut faculty member a medical sociologist from the University of Antwerp visited the UP and the three way collaboration began. In response to a combination of felt needs at the UP, emerging trends in international health in the Universities of Connecticut and Antwerp, and priorities of international donor agencies, the Triangle Programme was developed with funding support from the Belgian Development Aid Agency, Flemish Inter-University Council and the Commission of European Communities. Since the University of Antwerp was instru- mental in securing funds from the relevant donor agencies funds were channelled through this Belgian university.

Due to our focus on the transdisciplinary model this paper analyzes the working of the local rather the international triangle presented above. In effect we examine to what extent there was a cross fertilization among medicine, agriculture and social sciences at the UP as an outcome of the Triangle Programme.

The setting

The UP is one of the leading centres of teaching and research in Sri Lanka. Set up in 1949 following the University of London as its model, the UP has strived to maintain high academic standards in an environment of funding shortages, growing pressures for expansion of university education, brain drain and student radicalism. The university consists of seven faculties which concentrate on undergraduate educa- tion. There is also a Post-Graduate Institute of Agriculture. The Faculty of Arts,

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which is a leading centre for social science education in the country and which has produced some internationally renowned academicians, has traditionally favoured academic and critical thinking as opposed to applied concerns. In contrast, the Faculties of Medicine and Agriculture have always had a heavy practical orientation with direct service responsibilities in clinical and field settings. For instance, the staff of the Medical Faculty serves in two teaching hospitals and one public health field unit and the Faculty of Agriculture has been involved in agricultural research and extension in selected field stations.

The education system in the country has developed in a way that creates a gulf between arts and science 'streams' from secondary education onwards. Collaborations between different disciplines, particularly between social scientists and the so-called 'hard scientists' have been few and far between. The separations between 'Faculties' and 'Departments' within each Faculty have acquired an unusual rigidity preventing desired cross-disciplinary collaborations. There have been some isolated projects where multidisciplinary and, to a lesser extent, interdisciplinary collaboration was attempted but often they were externally stimulated, short lived or uninsitutionalized. Where social scientists participated in these collaborative projects they were often denied a parity in status in relation to those in technical fields. Under these circumstances certain research institutes created outside the university system have provided a somewhat better atmosphere for cross-disciplinary collaboration making it difficult for the universities to attract funds and play their legitimate role in influencing social policy and developments in the larger society. The results of the Triangle Programme in capacity building geared to collaborative health research must be viewed against this background.

Objectives

The specific objectives of the Triangle Programme were as follows: 1. To promote institutional capability at the UP for undertaking applied health

social science research useful to the country. 2. To promote collaboration between two developed country universities and one

developing country university in health social science research and training. 3. To promote inter-departmental and inter-faculty collaboration in applied health

research within the UP. 4. To promote communication between university-based health social science

researchers and decision makers in the relevant fields.

Strategies

The programme was administered by a Steering Committee consisting of six senior faculty members representing the three universities (3 from UP, 2 from Connecticut and 1 from Antwerp). The Triangle Programme combined the elements of research, training and institutional capability building in an integrated programme designed to develop applied health social sciences in a developing country setting. The pro- gramme consisted of the following steps:

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1. The selection of a core of university researchers distributed in the three relevant faculties at the UP.

2. Training and consultancy support towards the development of project proposals. 3. Implementation of projects by the individual researchers with consultancy and

institutional support provided under the programme. This was accompanied by development of required infrastructure and institutional arrangements at the UP.

4. Training and consultancy support for data analysis and report writing. 5. Dissemination of research results. Detailed activities under each of these steps are discussed below.

Selection of researchers

In the fall of 1989 the applications for research and training under the Triangle Programme were solicited from all interested researchers in the Faculties of Arts, Agriculture and Medicine at the UP. The application required a brief research proposal and an indication of how the project would benefit the applicant, the university and the country. The applicants were informed that the project proposals must deal with a priority research topic in the broad area of social and economic aspects of health. Twenty-five applications were received and interviews were held in Sri Lanka in January 1990. Fifteen applicants were selected for the programme. They represented a range of disciplines including Economics, Sociology, Geography, Psychiatry, Anatomy, Pediatrics, Community Medicine and Dentistry. In selecting the successful applicants, efforts were made to represent different disciplines, genders and ethnic groups. The career levels of the participants ranged from Assistant Lecturer to Associate Professor. The level and type of prior research experience and background in community health varied with some having a predominantly clinical experience and others with a strong track record in academic research. Two of the selected applicants were unable to join the programme for personal reasons, and two others dropped out of the programme after receiving the preliminary training in order to accept a post-graduate scholarship overseas. Another participant in the programme went on sabbatical leave halfway through the programme but his project was continued by one of his colleagues in the same discipline. A list of projects completed is given in Table 1.

Development of project proposals

Following their selection to the programme the participants were required to do further library research on their topics using library resources in Sri Lanka assisted where necessary by library searches in the two developed country universities. Subsequently they participated in a training workshop held in the University of Antwerp in July-August 1990. This workshop, which was of one month's duration, provided rapid health social science training and helped the participants develop their individual project proposals. The topics covered included identification of research problem, research design, data collection procedures, data entry and com- puter software. A team of instructors with long experience in applied health research, drawn from the three collaborating universities, conducted this workshop; they included anthropologists, sociologists, an epidemiologist, a pediatrician, an econo- mist and a statistician. One month's intensive study and joint participation in this

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TABLE 1

List of research projects completed under the Triangle Programme

Name of researcher Field Topic

C. Sivayoganathan (PhD) Agriculture Extension

H.V.A. Wikramasuriya (PhD)

A. Wikramasinghe (PhD)

M.W.A. de Silva (MSc)

H.M.D.R. Herath (MA)

A.S.B. Wijekoon (MD)

M.S. Chandrasekera (PhD)

A.S.P. Abhayaratne (BA)

M. Indran (PhD)

E.K. Rodrigo (MD) and P. Abeygunawardena (PhD) D.B. Nugegoda (MSc) and S. Balasuriya (PhD)

Agriculture Extension

Geography

Sociology

Sociology

Pediatrics

Anatomy

Economics

Anatomy

Psychiatry Agricultural Economics Community Medicine Community Medicine

Disease symptoms of pesticide applicators in vegetable cultivation in Sri Lanka Lessons from a home garden project in Sri Lanka Health consequences of development: the case of Kotmale Social and cultural factors affecting pregnancy outcomes Food taboos and practices during pregnancy Early infant feeding in a rural Sri Lankan population Beliefs and practices in infant feeding Reproductive choices of women in a rural area in Sri Lanka Inherited disorders and consanguinity: a knowledge and attitudes study in Sri Lanka Cost of mental illness in an urban population in Sri Lanka Health and social status of an elderly population in Sri Lanka

workshop provided a unique opportunity for the participants to interact across disciplinary and faculty boundaries. The participants themselves provided valuable inputs to one another in the development of the project proposals and, given the range of disciplines represented, this itself was a significant exchange of views and experience. In addition to common lectures and discussion sessions, the participants received individual consultations from selected instructors depending on their requirements. A team of consultants representing the three universities and different disciplines worked with the principal investigators (PIs) in each project to facilitate sustained inputs from the relevant disciplines for each project. Except for one joint research project where an agricultural economist and a psychiatrist served as co-principal investigators, PIs in each of the other projects came from one or the other of the collaborating Departments at the UP. As will be explained, during their development the project proposals gradually transcended the narrow disciplinary bounds within which they had been originally conceived. Each project proposal went through several drafts during the workshop and revised project proposals were presented and adopted at a concluding session of the workshop attended by all participants and instructors.

Project implementation

At the end of the first workshop each of the 11 projects developed by the researchers received a grant of about US$3000. The researchers were required to implement the

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relevant projects over a one year period from August 1990 to July 1991. As a follow up to the first workshop the researchers were asked to contact appropriate interven- tion programmes in Sri Lanka and develop a dialogue with them in the process of implementation of their research. With funds under this programme a resource center was developed as a part of CICHS at the UP. This resource center provided computer and other technical facilities as well as library services to the researchers and facilitated continued interaction among the Triangle participants. The consul- tants met the researchers several times during the implementation phase and made some mid-course adjustments in the projects where necessary. Several of the research- ers used a common formula for assessing socio-economic status developed as a part of the Triangle Programme. The researchers received group and individual consulta- tions from a biostatistician at the UP as they began data entry and preliminary data analysis.

Advanced data analysis and report writing

The researchers participated in a second workshop held in the University of Antwerp in July-August 1991 with a view to enhancing their data analysis and report writing skills. The researchers refined their data analysis during this workshop and produced a draft report that was presented to the workshop at its conclusion. Each data set was reviewed by a multidisciplinary team which presented varied and at times conflicting angles for the consideration of the principle researchers. Once again researchers received individual consultation in the different disciplines and participa- ted in a process of peer reviewing.

Dissemination of research results

From the outset it was anticipated that one of the desired outcomes of the Triangle Programme was to enable the researchers/newly trained health social scientists to influence the decision making processes in the relevant intervention programmes. A summary report containing preliminary findings and recommendations of these projects, entitled Feedback from Health Social Science Research in Sri Lanka, was prepared and circulated among policy makers, programme administrators and other researchers in Sri Lanka in December 1991. This was followed up by a national seminar held in Colombo on June 12, 1992 in which the researchers discussed their findings and recommendations with an audience of policy makers and programme administrators representing both government and non-government organizations involved in health related activities. This workshop generated a lot of useful discus- sion about the policy implications and some limitations of the relevant research findings as well as possibilities for future collaborations between the interventions programmes and the university.

In addition to the above efforts at dissemination of research results within Sri Lanka, a selection of articles produced under the Triangle Programme will be published shortly as a 'Symposium' in the International Journal 'Social Science and Medicine'.

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Broad themes in research and training

Under this programme thirteen researchers at the UP received a year long training in applied health social science research from problem identification and proposal development to report writing and dissemination of research results. Training in health social science research methodology served to provide a bridge among the researchers from different disciplines. Further the institutional capabilities of the CICHS, an inter-faculty entity committed to transdisciplinary collaborations in health research, were strengthened so as to provide an organizational forum for continued collaborations among the researchers from different disciplines. The research projects completed under this programme are listed in Table 1.

A strong transdisciplinary orientation to health is either implicit or explicit in all the studies conducted under the Triangle Programme. Three of the studies explore the relationship between agriculture and health. They examined the health outcomes of exposure to pesticides (Sivayoganathan), possibilities for developing home gardens as a means of augmenting nutritional intake of the farm families (Wikramasuriya) and health and ecological impact of irrigation development and human resettlement under one of the largest development programmes in the country (Wikramasinghe).

The next four studies examined maternal and child health issues in relation to the economic, social and cultural factors affecting them. All of these studies are directly or indirectly concerned with the issues of nutritional deficiencies widely and increas- ingly reported in rural Sri Lanka. While de Silva and Herath both focused on social and cultural factors affecting maternal malnutrition during pregnancy, Wijekoon and Chandrasekara studied infant feeding practices as they impact on the nutritional status of the growing child. In her study Abhayaratne examined contraceptive use in a sample of rural women with a family size of three children. The last three studies under this programme paid attention to three poorly understood but signifi- cant health problems in Sri Lanka. They relate to cost of mental illness (Rodrigo and Abeygunawardena), knowledge and attitudes about cross-cousin marriage and disease inheritance (Indran), and health problems of the elderly (Nugegoda and Balasuriya).

The recommendations based on these studies stressed practical, low-cost and community-based strategies such as development of home gardens guided by an understanding of family nutritional requirements, development of health education programmes targeted for pesticide applicators, men and women of marriageable ages, pregnant mothers, mothers with new-born infants and potential contraceptive users and intersectoral collaboration among agencies responsible for health, develop- ment and social welfare. The extent to which these studies influenced policy and intervention programmes is yet to be determined but it is anticipated that due to their conscious effort to transcend narrow disciplinary concerns, dialogue with the decision makers and organized forum in the form of CICHS these researchers have a better chance of introducing desired changes in health and related fields.

Towards a transdisciplinary approach to health

The Triangle Programme highlighted the value of promoting interdisciplinary collab- oration in health research in a developing country setting. The rapid training in

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health social science research methodology enabled the researchers to overcome the limitation of their respective disciplines by working in a transdisciplinary atmosphere. Each discipline represented in the group made a contribution towards cross fertiliza- tion of ideas within the group. Social scientists in the group helped clarify socio- economic status which proved to be a key variable in almost all the studies. The anthropologists helped apply qualitative research techniques in a variety of projects including those carried out by certain researchers from Medical and Agriculture Faculties. A good example of the beneficial effect of assimilation of research tech- niques from other disciplines is the use of the anthropological software package ANTHROPAC by a researcher from the Agriculture Faculty to determine local perceptions of the food value of selected home garden crops. Social science techniques such as key informant method and focused group discussion became standard research techniques in a variety of studies.

Similarly epidemiologists and clinically oriented researchers coming from biomedi- cal backgrounds helped develop measurements of morbidity and ill-health, which posed special problems for several researchers from the Faculties of Arts and Agriculture. Epidemiologists and certain researchers in agriculture-related fields had stronger backgrounds in quantitative research techniques and this facilitated cross fertilization of qualitative and quantitative research capabilities within the group. Largely influenced by the practical orientation of medicine and agriculture, 'So what?' questions were constantly raised at various stages of the development of the research projects and data analysis, making it necessary for the researchers to constantly orient themselves to the questions of how their research results would be of practical use to policy makers, programme administrators or community organiza- tions in the relevant fields, or the public at large.

The cross-fertilization aspects of the collaborations involved may be illustrated by briefly considering one of the Triangle research projects. In his study of disease symptoms of pesticide applicators in vegetable cultivation Sivayoganathan brought with him his disciplinary interest and years of experience in agricultural extension. Commercialized vegetable cultivation has received high priority as an emerging development in rural agriculture in parts of Sri Lanka. In developing a list of relevant disease symptoms that are likely to be encountered among the pesticide applicators, he was guided by epidemiologists and clinicians who had a better grasp of identifying and measuring symptoms of ill-health. Further medical anthropologists in the group made him sensitive to the pesticide applicators' own perception of pesticides and their effects, the language they use in classifying pesticides and describ- ing any disease symptoms attributed to the pesticides, and their behavior in dealing with pesticide application. In focusing attention on an emerging and poorly studied health problem, therefore, this study benefited from the researcher's prior back- ground in agricultural extension as well as the opportunities provided by the Triangle Programme for assimilation of inputs from other disciplines.

Not all participants in the Triangle Programme responded to its various compo- nents equally favorably, however. Disagreements and, at times, heated arguments were common between those in different disciplines, particularly during the first training workshop held in Antwerp. It appeared as though each discipline tried to prove that it had the most to offer and the least to learn from other disciplines present in respect of the research topic at hand. As the programme unfolded those in different disciplines tended to develop some degree of mutual understanding and

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even a respect for one another's view points. The CICHS emerged as an important rallying point for researchers from different disciplines who had a common interest in pursuing transdisciplinary research on health in community settings. How these researchers will utilize their new capabilities and to what extent and in what ways the collaborative spirit will continue are by no means certain; a lot will depend on availability of future funds for this kind of collaborative research and recognition accorded to such research within the university, the country at large and relevant international forums.

In conclusion, a key lesson to be learnt from the Triangle Programme in Sri Lanka is that under right conditions a rapid training in health social science research methodology can influence a cohort of researchers from diverse disciplines to devel- oping a transdisciplinary approach to health. However it must be pointed out that such short-term training programmes alone can not ensure long-term collaborations in health research in developing country settings. Long-term support for building of institutions favouring collaborative health research is needed along with desired changes in higher education policies, career paths for university-based applied researchers and a reorientation of goals of university academics from publications to practice. On the whole capacity building in developing countries requires appropriate partnerships at local, national and international levels.

References

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Rosenfield, P.L. (1992) The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences. Soc. Sci. Med. 35, 1343 1357.

Schensul, S. (1993) Extending anthropological contribution to prevention of Aids. Paper presented at the American Anthropological Association Meeting, November 17 21, 1993, Washington.

Silva, K.T., Aponso, H.A. and Peeters, R. (eds.) (1992) The Triangle Programme: Feedback from Health Social Science Research in Sri Lanka (Summaries of Recommendations for Decision-makers). Peradeniya: Centre for Intersectoral Community Health Studies, University of Peradeniya.

Trostle, J. (1992) Research capacity building in international health: definitions, evaluations and strategies for success. Soc. Sci. Med. 35, 1321-1324.

Trostle, J. and Simon, J. (1992) Building applied health research capacity in less-developed countries: problems encountered by the ADDR project. Soc. Sci. Med. 35, 1379-1387.

Vlassoff, C. and Manderson, L. (1994) Evaluating agency initiatives: Building social science capability in tropical disease research. Acta Trop. 57, 103-122.