Trajectories: The social science of developmental pathways to health from preconception to childhood in South Africa

In the 21st century, scientific advances have fundamentally challenged the view that an individual's health and well-being is written into their genes. Human development and health are now understood as profoundly shaped by early life environmental conditions. There have been significant public health investments in developing interventions during pregnancy and early childhood, particularly for decreasing obesity and non-communicable disease in the next generation. Recent evidence shows that interventions in pregnancy for decreasing obesity risk is of limited efficacy, and scientists are turning to the period before conception as a window of opportunity to shape intergenerational health. Testing this theory requires clinical trials that start before pregnancy and measure outcomes in the next generation.

These new scientific approaches raise important questions that require urgent consideration given their possible societal impacts. The 'preconception' focus could productively emphasise the wide range of social determinants of health, but also has the potential for a loss of gains in reproductive rights and gender equality, and diminished attention to the social drivers of health inequities. As evidence from preconception trials begins to shape global health policy on women's and children's health, it is crucial that we advance our knowledge of how our social environments get 'under the skin' to shape health outcomes.

This timely programme of research meets the urgent need for
(1) Social science attention to the social and ethical implications of research and intervention in the 'preconception period', including how preconception trials are conducted, the assumptions underpinning this research, and what this means for global public health policy;
(2) Innovative qualitative methodologies for studying the social factors that shape life trajectories.

To do this, the PI and team hosted at King's College London will partner with the Developmental Pathways for Health Research Unit at the University of the Witwatersrand in South Africa, who have recently launched a preconception trial as part of the Healthy Life Trajectories Initiative (HeLTI) study. This trial is hosted by the World Health Organisation and will be conducted in Canada, India, China and South Africa. The trial will recruit 6000-9000 women in each site and it will primarily assess the effects of a complex set of nutrition and behaviour change interventions on early childhood development outcomes and child obesity risk at age 5. Drawing on the Fellow's expertise as a clinician and anthropologist, and an excellent interdisciplinary team of anthropologists, bioethicists and public health researchers, this project will conduct the first ethnography of a preconception trial and will initiate the first qualitative longitudinal study of a cohort of this kind, tracking sixty women enrolled in the HeLTI trial for a 5-year period to trace the interaction of the social and biological factors that shape health outcomes - from preconception to early childhood, and across the life course.

This project will advance our theory and understanding of the social contexts of early life development and obesity risk; improve scientific practice; and create a space for public dialogue on the implications of new scientific knowledge for how we understand patterns of intergenerational health and disease. It will offer ground-breaking insights into how life course interventions can work most effectively to decrease health inequities, and will build the interdisciplinary research capacity needed to achieve this aim.

Impact beneficiaries, benefits, and impact goals:

1. Key health policy actors
-HeLTI hosts and partners: World Health Organisation (Maternal, New-born, Child and Adolescent Health Unit); research agencies of Canada, India, China, South Africa; UNICEF; United Nations Population Fund; Early Childhood Development Action Network; Open Society Foundations
-Nutrition, women's and children's health actors: Global Fund, Partnership for Maternal, Child and New-born Health, GAVI, Médecins sans Frontières.
-Africa Evidence Network members (3000)
-Gauteng Department of Health (Nutrition, Women's and Children's Health units); South African National Health Research Committee
How they benefit: The impact goal is to effect high-level policy change around life course public health intervention strategies by providing a rich data set that will improve policymakers' knowledge of the complex dynamics underpinning health outcomes and help to identify best points of intervention. The HeLTI trial outcomes are expected to influence global and national policy on non-communicable disease prevention and early childhood development. The proposed research integrates innovative qualitative research into the trial, which will have conceptual and instrumental impact on how trial evidence is understood, contextualised, and taken up in policy. Anticipated impacts include: improved frameworks of life course interventions that avoid gendered assumptions about women's reproductive strategies; improving policy responsiveness to local contexts and a more compelling narrative for high level policy action on decreasing health inequities.

2. South African non-governmental organisations and civil society: Centre for Early Childhood Development (CECD), National Adoption Coalition SA, Centre for Justice and Crime Prevention; Sonke Gender Justice, Save the Children SA
How they benefit: South African NGOs working on issues including nutrition, women and children's health and violence prevention will be both constituents and beneficiaries. Impacts for this group will include more effective programme implementation and advocacy.

3. 'Trajectories' participants (60)
How they benefit: this project includes well-researched community participatory methodologies such as photovoice and film that will be suitable to this community given South Africa's high levels of digital literacy. Impacts include:
-Participants' increased knowledge and skills through training in technical aspects of taking photographs, conducting ethical research, and sharing outcomes.
-Participants' increased recognition and empowerment to define and shape their community's presence and voice on issues of importance to them, to effect individual and social change.
-Expansion of participants' social networks, developing their platforms for advocacy and engagement to effect social change beyond the life of the project.

4. Wits and KCL university communities (staff, students, alumni, affiliates, visitors, online)
How they benefit: The impact goal to deliver societal impact by increasing knowledge and understanding of the social factors that shape intergenerational health and heredity. Project outputs for this include a film, photovoice exhibition, project website, and online media.

5. Soweto ('Trajectories' participants wider community)
How they benefit: The photovoice exhibition and film will be shared in Soweto at a local cultural centre and at annual events such as Soweto Arts Week. In addition to benefits as in (4), this delivers economic impact by promoting local venues and increased visitor numbers.

6. SA CECD Museum of Childhood (confirmed participation)
How they benefit: The newly opened museum will receive publicity and donation of materials for its archive. The impact goal is to promote societal impact with a wide audience by making resources accessible beyond the life of the project.