BESSI Collaboration: Bridging disciplinary barriers to fight pandemics

The BESSI Collaboration conducts interdisciplinary research and fosters evidence uptake so that behavioural/environmental/social/systems interventions help reduce viral transmission.

Susan Michie, Professor of Health Psychology, Director of the Centre for Behaviour Change, University College London. She is a member of Independent SAGE, and co-founder of the BESSI Collaboration.

SARS-CoV-1&2 highlighted on a global scale how unprepared societies are for pandemics, and how narrowly focused knowledge used to fight the pandemic is. Research responses remain narrowly focused on clinical and pharmacological solutions, ignoring that human behaviour and context matter most in controlling infectious diseases, including endemic, seasonal, and periodic infectious diseases that will remain major causes of morbidity and death. 

Key to fighting infectious diseases are behavioural/environmental/social/systems interventions (BESSIs), such as personal protective behaviours (behaviour), sanitation and ventilation (environmental), trust/ governance (social) and test/trace/isolate (systems). Countries that promoted BESSIs as crucial achieved near-zero COVID-19. 

Two obstacles block utilising the power of BESSIs in pandemic management and prevention:

1. Funding priorities: Research on developing, optimising, and implementing BESSIs is scarce. Less than 4% of global COVID-19 research funding has supported BESSI work. Only 13 out of 2168 COVID-19 registered randomised controlled trials evaluate BESSIs and support our learning.

2. Disciplinary barriers: Few attempts are made to boldly cross disciplinary boundaries. Understanding human health behaviours in context requires that academic disciplines combine forces to work across behavioural, implementation and medical sciences as well as include engineering, anthropology and political science to create a research and policy environment conducive for pandemic management and preparedness.

Our solution serves populations and decision-makers affected by, and dealing with, current and future epidemics and pandemics. These populations are best cared for through influencing the community of researchers, funders, policymakers, planners and others that are key to successful BESSI implementation. 

To engage our ever-expanding BESSI network in strengthening BESSI-driven solutions to pandemics, we: 

1. established a global network. The BESSI email list currently has more than 150 researchers, health policy makers, and practitioners from 28 countries subscribed to 141 posts; 34 topics have been covered. We also have 465 Twitter followers and an active website.

2. co-created with this BESSI network ‘The Seven BESSI Collaboration Principles’ to which an increasing number of individuals and organisations are signing up (www.bessi-collab.net/principles ).

3. organised a series of successful international webinars in 2020 on BESSI research and funding. www.bessi-collab.net/videos.  

4. curated a database of all BESSI trials with links to their protocols and results -  www.bessi-collab.net/research. These trials are being assessed for completeness with requests to investigators additional details, full protocols and data to be made public.

5. advocated to numerous funders about the over 100-fold difference between BESSI and pharmacological research funding, for example through a presentation to EVIR funder forum - https://youtu.be/l53l8qOs34c.

The seven BESSI Principles will be our guardrails to support developments of effective BESSIs. These principles are designed to function as a public good to support better BESSI research. BESSI protocols for all effective BESSI Collaboration research outputs will be freely available on our website as will access to all evidence-synthesis and summaries of published BESSI trials. 

Broad initial deliverables include:

1. a living evidence map of BESSI research; key living systematic reviews of BESSIs; new synthesis methods and tools; study protocols and research tools to enable rapid BESSI research during future outbreaks.

2. detailed information on enablers of and barriers to infection prevention in two country settings; feasible objective outcome measures; the design of rigorous (randomised or quasi-experimental) evaluations.

3. a new policy uptake model, expanding on existing frameworks for evidence translation, and based on empirical evidence from this collaboration. The model will describe a socially embedded evidence-to-action process that can be adapted to different moral, cultural, policy and information contexts.

BESSI-based pandemic management can be deployed instantly through appropriate policy and behaviours. This use should also be considered an opportunity to study and learn how to improve the BESSI effectiveness and reduce downsides. Hence promotion of research, research funding, and engagement of policy and implementation represents a huge – and currently largely missed – opportunity to reduce transmission while reducing societal harms.

Vaccine inequality is a huge and known problem. Particularly in countries underserved by vaccine availability, BESSI interventions that strengthen trusting relationships between public health authorities and populations will remain the first line of defence against pandemics.  This is particularly true for underserved communities who cannot expect that large-scale systemic or infrastructural solutions will be forthcoming soon. Our approach to evidence, research and uptake models, with significant research emphasis and ownership in the Global South, allows us to offer swift, contextually-appropriate outputs.

It cannot be stressed enough how unfairly knowledge resources that can aid pandemic preparedness are currently distributed. This also means that BESSI knowledge, which has to be context-specific as it requires humans, their environments, their social and institutional worlds, is extremely limited when it comes to Global South countries. Populations in these settings will benefit tremendously. 

The BESSI Collaboration takes its approach to scaling from international development work in fragile settings, where most recent thinking points out the need to simultaneously address urgent needs (such as acute pandemic management) and address root causes of lacking pandemic preparedness (see for example Cooley & Papoulidis, 2018, https://link.springer.com/article/10.1057/s41301-018-0155-8?shared-article-renderer). This approach comes from lessons learned that pilot-based scaling is too slow and not able to adjust flexibly.

The ‘bonding, bridging, linking’ approach suggested in this novel approach champions strengthening collaborative social ties, maximising capacities, and linking efforts through information sharing. With the BESSI Collaboration, we thus move away from the simplified notion of pilot-based scaling. Instead, our approach means to simultaneously strengthen broader research ownership and capacity by promoting international and interdisciplinary collaborations and building on existing data sets mentioned above, integrating evidence uptake into research through our proposed contextualised approach to evidence uptake and using remote data collection technology to conduct even preliminary research at scale and with comparison sites. The multiple disciplinary perspectives represented in the BESSI Collaboration also allow us to identify what is necessary to pursue a more agile and effective approach to scaling: The ability to swiftly diagnose challenges and implement course corrections.  

Our goals and key performance indicators (KPIs) are:

1. Goal: to promote and conduct interdisciplinary, translational BESSI research on transmission reduction and develop preparedness/responsiveness for diverse infectious diseases

   1. KPI: Attendance, interest and engagement: Number of attendees, subscribers, follow-up

   2. KPI: Fundraising efforts: Measure how many international funding proposals submitted (so far, one large 4-year grant application submitted)

2. Goal: create a living evidence repository on the effects of BESSIs, implementation issues and contextual effects to support decision-makers,

   1. KPI: establish a current and updated database of BESSI research

   2. KPI: provide evidence summaries of BESSI research

   3. KPI: refine and curate protocols of effective BESSIs for open use

3. Goal: build a global interdisciplinary community of BESSI researchers with a focus on Global South research.

   1. KPI: increase the number of BESSI Collaboration members (currently >150)

   2. KPI: expand the number of members in the BESSI Collaboration from the Global South  

   3. KPI: attract a breadth of researchers from multiple disciplines 

   4. KPI: strengthen research ownership in the Global South (headquartering BESSI in Kenya)

   5. KPI: Attract international funding for a Global-South headquartered international collaboration

We are aware of multiple barriers:

• Translational barriers

The BESSI-Collaboration requires global leaders who synthesise evidence, generate BESSI research evidence and those who translate and embed this evidence into health policy.

• Funding barriers 

Funders often struggle to fund genuine interdisciplinary work, as evaluating its value requires breadth of expertise. 

• Disciplinary barriers

For behavioural, medical, environmental, and social scientists to work together a collaborative mindset, patience and an appreciation of how empirical evidence is understood differently across disciplines are required. In addition, many methods or analytical frameworks developed in the Global North require contextually appropriate adjustment in the Global South. Willingness to adjust methods in culturally-appropriate ways is challenged through research funding that does not allow for the necessary interaction and communication between different disciplines.

Overcoming these barriers

Our collaborative effort in the past 8 months has taken us a long way towards overcoming the barriers. An important first step has been to take the lead and model this approach because there is currently a lack of global leadership that recognises the critical role of BESSI research during any infectious outbreaks, manifested by a significant lack of financial resources allocated to BESSIs compared with pharmaceutical interventions.

Bond University

Busara Center

Cochrane Acute Respiratory Infections group

COVID Circle (UKCDR/GloPID-R)

COVID-END

ICASR - International Collaboration for the Automation of Systematic Reviews 

Ottawa Hospital Research Institute

UK Independent SAGE

UK SAGE

University College London

University of Ottawa

WHO – Technical Advisory Group on Behavioural Insights and Sciences for Health

A common barrier to interdisciplinary collaboration is the transaction cost of working across different types of research and different categories of research institutions and funding. This barrier is even further enhanced when international collaboration emphasises working in the Global South, as much funding is still skewed towards the model of southern organisations being the subcontractors to northern institutions. The Trinity Challenge can help us overcome these barriers through exposure that allows us to advocate for the BESSI cause, funding, and networking.

We have made good progress in developing the BESSI-Collaboration using our existing networks and reputations as exemplar researchers. Our funding application to the Wellcome Trust is aimed at research work, which will also enhance the collaboration. However, for the BESSI-Collaboration to grow effectively and link research, researchers, policy makers and improve the lives of vulnerable populations, we need to also enhance the collaboration, linkage, lobbying and capacity building components. This requires a secretariat that can strengthen the Collaboration, strategically build relationships with relevant policymakers and adapt swiftly to respond to knowledge needs as they emerge during the current and future pandemics.

We are looking to partner with three categories of organisations:

• Those who would naturally be a good fit for the type of work BESSI does to become research and practice collaborators (such as Trinity Challenge Members Behavioural Insights Team and Institute for Health Metrics and Evaluation).

• Those who can support innovative thinking on technology for BESSI work to integrate innovative technology into our research designs (such as Trinity Challenge Members Google, Infosys and Palantir).

• Those who work in locations where BESSI support is particularly nascent to advance the collaborative work on BESSI research (such as Kenya Medical Research Institute and the Centre for Community Based Research in South Africa).

The key multinational organisations most closely aligned with BESSI goals are:

GLOPID-R - The Global Research Collaboration for Infectious Disease Preparedness

CEPI - The Coalition for Epidemic Preparedness Innovations

WHO - beyond the current membership of the Technical Advisory Group on Behavioural Insights and Sciences for Health

(and we have had discussions with members of GLOPID-R and WHO).