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

在21世纪，科学的进步从根本上挑战了个人的健康和幸福是写在他们的基因中的观点。人类的发展和健康现在被理解为深受早期生活环境条件的影响。在制定孕期和幼儿期干预措施，特别是减少下一代肥胖和非传染性疾病方面进行了大量公共卫生投资。最近的证据表明，在怀孕期间进行干预以降低肥胖风险的效果有限，科学家们正将怀孕前的一段时间作为塑造代际健康的机会之窗。为了验证这一理论，需要在怀孕前就开始临床试验，并对下一代的结果进行测量。这些新的科学方法提出了一些重要的问题，考虑到它们可能产生的社会影响，这些问题需要紧急考虑。“先入为主”的重点可以有效地强调健康的广泛社会决定因素，但也有可能丧失生殖权利和性别平等方面的成果，并减少对卫生不平等的社会驱动因素的关注。由于来自孕前试验的证据开始影响有关妇女和儿童健康的全球卫生政策，至关重要的是，我们必须增进对社会环境如何“在皮肤下”影响健康结果的认识。这一及时的研究计划满足了以下迫切需要：(1)社会科学关注“孕前期”研究和干预的社会和伦理影响，包括如何进行孕前试验，支撑这项研究的假设，以及这对全球公共卫生政策意味着什么；(2)研究影响人生轨迹的社会因素的创新定性方法。为了做到这一点，PI和伦敦国王学院的团队将与南非威特沃特斯兰德大学的健康发展途径研究部门合作，后者最近启动了一项孕前试验，作为健康生活轨迹倡议（HeLTI）研究的一部分。该试验由世界卫生组织主办，将在加拿大、印度、中国和南非进行。该试验将在每个地点招募6000-9000名妇女，并将主要评估一套复杂的营养和行为改变干预措施对儿童早期发展结果和5岁儿童肥胖风险的影响。利用该研究员作为临床医生和人类学家的专业知识，以及由人类学家、生物伦理学家和公共卫生研究人员组成的优秀跨学科团队，该项目将进行第一次先入为主的人种志试验，并将对这类队列进行第一次定性纵向研究。对60名参加HeLTI试验的妇女进行了为期5年的跟踪调查，以追踪影响健康结果的社会和生物因素之间的相互作用——从孕前到幼儿期，以及整个生命过程。这个项目将推进我们对早期生活发展和肥胖风险的社会背景的理论和理解；加强科学实践；并创造一个公众对话的空间，讨论新科学知识对我们如何理解代际健康和疾病模式的影响。它将提供关于生命过程干预如何能够最有效地减少卫生不公平现象的突破性见解，并将建立实现这一目标所需的跨学科研究能力。

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.