Testing on the frontline: empowering health engagement through ‘rational use’ of diagnostics for infectious and non-communicable disease

Background: Sub-Saharan Africa faces a double disease burden of non-communicable and infectious disease. Earlier diagnosis can lead to improved outcomes. Decentralised access to diagnostics through self-testing has substantial potential to address global diagnostic gaps, democratise health and contribute to Universal Health Coverage. An exponential growth in the self-testing market, predicted to increase to 13.6 billion USD by 2033, is improving access. However, unregulated and uncontrolled access has the potential for unintended consequences. This project will address a critical gap in how best to approach self-testing and self-monitoring for infectious and non-communicable disease to respond to the World Health Assembly call to develop national diagnostics strategies. Research Question: How does the introduction and use of frontline diagnostics for self-testing and monitoring change the ways individuals and communities in low and middle-income countries engage with health and how can use be optimised to contribute to promoting health equity and people-centred self-care? Aims and Objectives: I will focus on understanding the potential and actual, intended and unintended harms and benefits and 'rational use' of self-testing for HIV, Ebola and Type 1 and Type 2 diabetes. I will situate this through the lived experiences of individuals, families, communities and frontline health workers and the impact on management of health and well-being at home and through interactions with the primary health system. I will 1) define and document social and structural drivers of 'rational use' under conditions of stigma, emergency disease outbreaks and lifestyle and risk management, 2) unpack the dynamic between empowerment through self-testing and engagement with public and private health services, 3) explore uncertainty, trust and risk influencing decisions, embedded within complex socioecological environments and impact on intended and unintended, beneficial and potentially harmful health and social consequences, 4) co-produce toolkits for 'rational use' of frontline diagnostics and 5) promote health equity across mainstream and marginalised groups through 'rational use' of self-testing and monitoring that reflects direct to consumer markets. Methods: This is an anthropological research project using qualitative methods and situated at the interface of technology and society. The project will be delivered through four work packages using ethnographic observations, in-depth interviews, critical incident narratives, treatment journey modelling, focus group discussions, community consultation and participatory methods: Work Package 1: HIV and diabetes in rural and urban Malawi Work Package 2: HIV and frontline Ebola diagnostics in rural and urban Uganda Work Package 3: Community co-production of toolkits for 'rational use' of frontline diagnostics Work Package 4: Evidence to policy and development of framework for 'rational use' Timelines for delivery: Years 1 to 3 will focus on research components and initial community and policy engagement. Year 4 and 5 will focus on translational approaches. Community and stakeholder engagement will take place throughout to inform all stages of the project. Anticipated impact and dissemination: The work will inform national health strategies for scale-up of diagnostics and address inequalities in access to health empowerment through self-testing at a critical time as countries respond to the global call to address diagnostic gaps.