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Bangladesh collaborators: Prof Jahangir Khan and Prof Alayne Adams

Brazil collaborators: Prof Jorge Iriart, Mr Eduardo Marinho, Prof Vilma Santana, Ms Margarete Santos

Niger collaborators: Dr Djibo Douma and Mr Balla Souley

Building up the evidence base using rigorous research

Developing interventions that will make an impact

Sharing experiences of what works in practice

History and mission of the CLEAR Collaboration

In 2010, an international group of researchers and policy makers joined together forming the CLEAR Collaboration (Community Links Evidence to Action Research Collaboration) with the aim of: 1) better understanding how physicians, nurses and other allied health workers can address the social causes of poor health, and 2) creating clinical practice tools for frontline health workers to help them better support disadvantaged patients and promote action on broader social determinants in their local context.

With the generous support of research planning grants from the Canadian Institutes of Health Research (CIHR), Dr. Andermann organized a series of international research planning meetings held at McGill University in Montreal to determine the future direction of the Collaboration. This was followed by a Canadian Rising Stars in Global Health Award from Grand Challenges Canada, that provided operational funding for a realist review of the literature on what health workers can do to take action on the social determinants of health in clinical practice, as well as primary research in Brazil, Bangladesh, Pakistan and Niger with a focus on how health workers can best support a highly vulnerable patient population – notably children involved in hazardous child labour – as an entry point to better understanding this broadening scope of clinical practice.  

Funding sources and support for this research

This work has been made possible through the generous funding and support of the Canadian Institutes for Health Research, Grand Challenges Canada, Fonds de la Recherche du Québec-Santé (FRQS), Fédération des Médecins Spécialistes du Québec (FMSQ), St Mary’s Research Centre, and McGill University, Montréal, Canada.

Evidence for action on social determinants in clinical care

Our research has shown that while health workers generally recognize that social determinants influence the health of their patients, and agree that something should be done, they are often unsure what concrete actions they can use to make a difference. The main barriers to taking on a social determinants approach in clinical practice include a lack of role modeling, training, and time. However, clinicians who do know how to ask about the social challenges of their patients in a sensitive and caring way are more likely to report having helped their patient in working through and overcoming these issues.

The purpose of this programme of research is not only to build up the evidence base, but also to apply this evidence in developing practical tools to support busy clinicians and help them integrate a social determinants of health approach into everyday clinical care. The CLEAR toolkit is therefore one of the first clinical decision aids designed to help health workers assess different aspects of patient vulnerability in a contextually appropriate and caring way and easily identify key referral resources in their local area. While a growing number of clinical tools are being developed in high income country contexts, the CLEAR toolkit was created with community health workers in low- and middle-income countries also in mind.

The toolkit has undergone successive rounds of expert feedback, piloting with health workers and revisions. It is now being implemented and evaluated in a number of different contexts around the world to measure the impact on: 1) patient health and social outcomes, 2) levels social support and 3) patient experiences of clinical care. Our research confirms that this innovation is welcomed by frontline health workers who consider that such training and guidance is critical for being able to address the underlying causes of poor health in their day-to-day practice.

Bringing together researchers and policy-makers

The CLEAR collaboration during their 2nd international planning meeting at McGill University in 2012. Back row (left to right): Mr Ibrahim Balla Souley (Niger), Will Affleck (Canada PhD student), Margarete Santos (Brazil PhD student), Prof Jorge Iriart (Brazil), Nazmul Alam (Bangladesh Postdoctoral fellow), Dr Vilma Santana (Brazil), Prof Jahangir Khan (Bangladesh), Mr Saeed Awan (Pakistan). Front row: Prof Alayne Adams (Bangladesh), Dr Djibo Douma Maiga (Niger), Dr Anne Andermann (Canada), Dr Susan Gunn (ILO observer), Dr Ann Macaulay (Canada), Dr Ali Okhowat (Canada PhD student).

The CLEAR collaboration includes experienced researchers from leading research institutions around the world, high-level knowledge users from national ministries of health, interdisciplinary experts, and observers from international organizations:

Tajul Islam Abdul Bari, Deputy Programme Manager, Child Health Programme, Directorate General of Health Services (Dhaka, BANGLADESH); Alayne Adams, Senior Social Scientist, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh (Dhaka, BANGLADESH); Anne Andermann, co-Founder and Director, CLEAR Collaboration, Associate Professor, Department of Family Medicine, McGill University (Montreal, CANADA); Lisa Andermann, Assistant Professor, Division of Equity, Gender and Population, Department of Psychiatry, University of Toronto (Toronto, CANADA); Saeed Awan, Director, Centre for the Improvement of Working Conditions & Environment, Department of Labour and Human Resources, Government of Punjab (Lahore, PAKISTAN - deceased); Theresa Betancourt, Director, Research Program on Children in Global Adversity, Harvard School of Public Health (Boston, USA), Ryoa Chung, Associate Professor, Department of Philosophy, Université de Montréal (Montreal, CANADA); Myriam Denov, Associate Professor, School of Social Work, McGill University (Montréal, CANADA); Hannah Sarah Dini, Project Manager, One Million Community Health Workers Campaign, Earth Institute, Columbia University (New York, USA); Peter Dorman, Professor, Department of Economics, The Evergreen State College (Olympia, USA); Djibo Douma, National Program Coordinator, Department of Neuropsychiatry, Université Abdou Moumouni (Niamey, NIGER); Timothy Evans, Director, Health, Nutrition and Population, The World Bank (Washington DC, USA – observer); Rebecca Freeman Grais, Director, Epidemiology and Public Health, Epicentre - Médecins Sans Frontières (Paris, France); Susan Gunn, Senior Technical Specialist, Hazardous Child Labour, International Labour Organization (Geneva, SWITZERLAND – observer); Jorge Iriart, Professor, Institute for Collective Health, Federal University of Bahia (Salvador, BRAZIL); Kirsten Johnson, Director, McGill Humanitarian Studies Initiative, Department of Family Medicine, McGill University (Montreal, CANADA); Jahangir Khan, Lead Health Economist, International Centre for Diarrhoeal Disease Research, Bangladesh (Dhaka, BANGLADESH); Nicholas King, Director, Measurement, Ethics and Decision-Making Collaborative, McGill University (Montreal, CANADA); Marc Laporta, Director, Montreal WHO/PAHO Collaborating Centre for Research and Training in Mental Health, McGill University (Montreal, CANADA); Ann Macaulay, Director, Participatory Research at McGill, Department of Family Medicine, McGill University (Montreal, CANADA); Farooq Naseer, Assistant Professor, Department of Economics, Lahore University of Management Sciences (Lahore, PAKISTAN); Muazzam Nasrullah, co-Founder, CLEAR Collaboration, Department of Community Medicine, West Virginia University (Morgantown, USA); Guilherme Netto, Director, Department of Environmental and Occupational Health, Brazilian Ministry of health  of Health (Brasília, BRAZIL); Kumanan Rasanathan, Health Specialist, Knowledge Management and Implementation Research Unit, Health Section, UNICEF (New York, USA – observer); Laila Salim, Senior Advisor, Health and Nutrition, Save the Children Canada (Toronto, CANADA); Vilma Santana, Director, Integrated Programme in Environmental and Occupational Health, Institute for Collective Health, Federal University of Bahia (Salvador, BRAZIL); Chiara Servili, Consultant, Department of Mental Health & Substance Abuse, World Health Organization (Geneva, SWITZERLAND – observer); Ibrahim Balla Souley, Administrator, International Programme on the Elimination of Child Labour, International Labour Organization (Niamey, NIGER); Joe Thomas, Executive Director, Partners in Population and Development (Dhaka, BANGLADESH).

In memoriam

It is with great regret and sadness that one of our key collaborators in Pakistan, Saeed Awan, a remarkable individual so devoted to improving the lives of hazardous child labourers, died prematurely in January 2014. He left behind his wife and 2 young daughters. It is a terrible loss to the global research community and to the many children that he was in the process of helping to navigate towards a brighter future. More recently, we were also very sad to learn of the unexpected death of Dr. Duncan Pederson who was part of two thesis committees focused on the piloting of the CLEAR toolkit in low- and middle-income countries. Dr. Pederson was an important figure in global health research at McGill and a world expert in global mental health [read more].

Saeed AwanSaeed Awan

What’s in a name?

The CLEAR Collaboration was first named the “Child Labour Evidence to Action Research Collaboration” due to the focus on child labourers as the entry point to addressing the intergenerational transfer of health inequities. However, through the course of our research, it became evidence that whether or not a child was working, they may share many of the same determinants of poor health including social isolation, living in degraded environments, and exposure to violence, and the key to supporting disadvantaged patients is linking them with existing resources and supports in their local community, thus the new name “Community Links Evidence to Action Research Collaboration.”