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Interdisciplinary knowledge translation and evaluation strategies for participatory dengue prevention… Mitchell-Foster, Kendra Lynn 2013

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       INTERDISCIPLINARY KNOWLEDGE TRANSLATION AND EVALUATION STRATEGIES FOR PARTICIPATORY DENGUE PREVENTION IN MACHALA, ECUADOR  by   KENDRA LYNN MITCHELL-FOSTER  B.Sc. (Hons.), University of Winnipeg, Winnipeg, 2004 M.Sc. Simon Fraser University, Burnaby, 2008     A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   DOCTOR OF PHILOSOPHY  in  THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Interdisciplinary Studies)     THE UNIVERSITY OF BRITISH COLUMBIA   (Vancouver)  October 2013     ? Kendra Lynn Mitchell-Foster, 2013  ii Abstract This dissertation explores how knowledge management approaches and socio-political systems affect the accessibility to and application of evidence to improve the health of socially and politically disempowered groups of people. As, dengue provides a particularly vivid example of a human health issue intricately linked to biological, environmental, social and political systems, this study is embedded in a participatory dengue prevention and control program in Machala, Ecuador, that is committed to capacity-building and scaling-up. Guided by a transformative emancipatory approach with a focus on equitable participation, a multi-method approach was pursued including ethnographically-framed stakeholder analyses, social network mapping and analysis, illustrative vignettes and participatory indicator development. Six major stakeholder groups were identified in Machala: community, local government, government functionary, government administrator, researcher and private sector. Varying degrees of collaboration and interaction with one another as well as with the problematic of dengue are shaped by the dynamics of differing health priorities, paternalism/equitable participation, quemeimportismo/social resentment, nepotism/centrism/social justice, marginalization/self-determination and Buen Vivir. Power dynamics and knowledge valuation schemes dictate definitions of success and shape evaluation tools and processes tend to marginalize experiential and tacit knowledge, perpetuating narrow conceptions of health, benefit and dengue transmission risk. Overall, opinions regarding evaluation criteria did not significantly differ by stakeholder group, which suggests that social and cultural dynamics, as well as history and narrative of place, may be far more important factors in determining both stakeholder priorities and the character of intersectoral spaces than previously thought. A participatory evaluation tool is developed to assess both impact and process-related performance of proposed dengue prevention and control strategies. A knowledge translation model is developed with a strong emphasis on equitable participation and health equity. This study observes that there is deep need for change in underlying institutional  iii power structures and research-to-policy processes, without which new evaluation tools will likely not ?make sense? or result in improved policy, programs and community well-being. These findings and their implications challenge current macro, mid and local-level knowledge management strategies. This study indicates that opportunity for change exists through participatory evaluation processes situated at the interface of equitable knowledge translation and social determination.   iv Preface  The research described in this thesis was conceptualized, designed and written up in full by myself, Kendra Mitchell-Foster, but is situated operationally within a larger three-year project called ?Meeting capacity-building and scale-up challenges to sustainably prevent dengue in Machala, Ecuador? (EBS-Ecuador). This larger project, built on the foundations of the pilot projects for Masters of Health with and Ecosystems Focus theses elaborated by Dr. Efra?n Beltr?n Ayala and Dra. Ana Arichabala Wilches in 2008, was designed and written through a collaborative research team comprising Dr. Jaime Breilh Paz y Mino, Dr. Jerry Spiegel, Dr. Efra?n Beltr?n Ayala and myself. The original proposal for the EBS-Ecuador project then underwent major revisions made by Dr. Efra?n Beltr?n Ayala and myself at the proposal development workshop for the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and International Development Research Centre (IDRC) Innovative Community-based Ecosystem Management Interventions for Improved Chagas Disease and Dengue Prevention in Latin America and the Caribbean held in Antigua, Guatemala, in July 2009. This newer iteration of the EBS-Ecuador project was further developed by the full research team and was funded in early 2010. The ecosystems approach for this work is described as Eco-Bio-Social (EBS), a three pronged approach to identifying, investigating and addressing determinants of health and disease risk through ecological, biological and social forces. The research presented here was designed and developed by me to address specific elements of the determination, determinants and risk factors within the social arm of inquiry of the overall EBS project design.   I undertook all ethnographic observation and analysis, interviews and focus groups, and with the exception of rough transcription support from research assistant Kelly Garton on three of the 41 sessions, were transcribed, coded and analyzed by me. I had the pleasure of working with a SNEM health promoter/vector control worker throughout the participatory indicator data  v collection process; Sra. Patricia Zhinin helped to administer surveys to participants, coordinate meetings and follow-up with home visits and telephone calls. The community participation, empowerment and well-being survey was administered to 1888 EBS-Ecuador project participants through the SNEM-based field brigades in conjunction with routine home visits as part of the overall project protocol. I undertook all instrument design, data entry, analysis, development of outputs and theories, and writing specific to this thesis. Robert Balshaw of the British Columbia Centers for Disease Control advised me on the use of principal component and hierarchical clustering analyses.  This study was approved by the UBC Behavioural Research Ethics Board (certificate H11-01327), and the overall EBS-Ecuador project within which this research is embedded was approved by the UBC Behavioural Research Ethics Board (certificate H10-00568) and the World Health Organization Ethics Review Board (ID A90294 / T16-TSA-225). This study was funded in part by the TDR-IDRC EBS-LAC initiative, and in part by a three-year Frederick Banting & Charles Best Doctoral Fellowship Canada Graduate Scholarship from the Canadian Institutes for Health Research awarded to me, Kendra Mitchell-Foster. vi  Table of Contents Table of Contents Abstract ........................................................................................................................... ii	 ?Preface ............................................................................................................................ iv	 ?Table of Contents........................................................................................................... vi	 ?List of Tables.................................................................................................................. ix	 ?List of Figures ................................................................................................................. x	 ?List of Abbreviations ..................................................................................................... xi	 ?Acknowledgements ..................................................................................................... xiv	 ?Dedication..................................................................................................................... xvi	 ?Chapter 1 - Introduction to the Study ........................................................................... 1	 ?1.1 SETTING THE SCENE ................................................................................................. 1	 ?1.2 AN INTERNATIONAL EFFORT TO STRENGTHEN DENGUE PREVENTION AND CONTROL ..... 5	 ?1.3 RESEARCH PROBLEM AND RESEARCH QUESTIONS...................................................... 7	 ?1.4 SIGNIFICANCE OF THE STUDY .................................................................................... 9	 ?1.5 OVERVIEW AND ORGANIZATION OF THE THESIS ........................................................ 10	 ?Chapter 2 ? Foundations of the Study ........................................................................ 14	 ?2.1 DENGUE FEVER IN LATIN AMERICA........................................................................... 14	 ?2.1.1 Dengue in Ecuador ........................................................................................ 17	 ?2.2 SOCIAL DETERMINANTS AND SOCIAL DETERMINATION OF HEALTH.............................. 21	 ?2.2.1 The importance of SDH in dengue prevention and control ............................ 24	 ?2.3 THE ECOHEALTH APPROACH AND THE ECO-BIO-SOCIAL PARADIGM.......................... 27	 ?2.4 INTRODUCTION TO KNOWLEDGE TRANSLATION ......................................................... 30	 ?2.4.1 History & theoretical roots of knowledge translation ...................................... 30	 ?2.4.2 Knowledge valuation schemes: historical & present ...................................... 35	 ?2.4.3 Implications for KT in the scaling up process................................................. 41	 ?2.5 PARTICIPATORY INDICATOR DEVELOPMENT .............................................................. 44	 ?2.5.1 Social multi-criteria evaluation as a participatory process ............................. 46	 ?2.6 THEORETICAL FOUNDATIONS FOR METHODOLOGICAL CHOICES ................................. 47	 ?Chapter 3 ? Methods..................................................................................................... 49	 ?3.1 MIXED METHODS FOR APPLIED HEALTH RESEARCH................................................... 50	 ?3.2 IMPORTANCE OF PARTICIPATORY METHODOLOGY..................................................... 55	 ?3.3 ECO-BIO-SOCIAL PROJECT DESIGN.......................................................................... 58	 ?3.3.1 Study area and participant groups ................................................................. 59	 ?3.4 ETHNOGRAPHY: A WINDOW ON SOCIAL DETERMINANTS OF HEALTH........................... 60	 ?3.4.1 Ethnographic field methods ........................................................................... 61	 ?3.4.2 Self-ethnographic reflections ......................................................................... 62	 ?3.5 SOCIAL NETWORK MAPPING AND ANALYSIS .............................................................. 67	 ?3.5.1 Toward a socio-cultural understanding of dengue ......................................... 67	 ? vii 3.5.2 The importance of social mapping ................................................................. 68	 ?3.5.4 Social network structure and function ............................................................ 70	 ?3.5.5 Centrality: degree, closeness, betweenness ................................................. 73	 ?3.5.7 Social network mapping methods .................................................................. 76	 ?3.5.8 Coding progression........................................................................................ 78	 ?3.5.9 Social network analysis.................................................................................. 79	 ?3.6 EVALUATION TOOL DEVELOPMENT ........................................................................... 79	 ?3.6.1 Participatory indicators and knowledge valuation .......................................... 80	 ?3.6.4 Indicator development methods..................................................................... 81	 ?3.6.5 Principal component analysis & hierarchical clustering ................................. 83	 ?3.7 COMMUNITY PARTICIPATION, EMPOWERMENT & WELL-BEING SURVEY ....................... 85	 ?Chapter 4 ? Results: Machala Network Mapping and Analysis................................ 87	 ?4.1 STAKEHOLDER ANALYSIS......................................................................................... 88	 ?4.1.1 Identified stakeholder groups and actors ....................................................... 90	 ?4.1.2 Cultural dynamics and the power of perception........................................... 125	 ?4.2 SOCIAL NETWORK ANALYSIS.................................................................................. 136	 ?4.2.1 Social network map...................................................................................... 137	 ?4.2.2 Three-in-one network model ........................................................................ 146	 ?4.2.3 Intersectoral spaces and macro-sector boundaries ..................................... 153	 ?4.2.4 Communication patterns and knowledge translation ................................... 155	 ?4.3 SOCIOCULTURAL DYNAMICS IN COMMUNITY-BASED DENGUE PREVENTION AND CONTROL: ILLUSTRATIVE VIGNETTES ........................................................................... 156	 ?4.3.1 Vignette 1: Quemeimportismo, evaluation and paternalistic assumptions... 156	 ?4.3.2 Vignette 2: Paternalism in socially-minded KT and the ?know-do gap?........ 161	 ?4.3.3 Vignette 3: Vacant lots, community health and the need for intersectoral collaboration.......................................................................................................... 167	 ?4.3.4 Summarizing the vignettes........................................................................... 173	 ?4.4 RESULTS SUMMARY: WHO AND HOW? ................................................................... 175	 ?Chapter 5 ? Results: Participatory Evaluation for Scale-up ................................... 177	 ?5.1 CONTEXT OF DENGUE POLICY IN MACHALA ........................................................... 178	 ?5.1.1 Reflections of policy stakeholder analysis ................................................... 180	 ?5.2 PARTICIPATORY INDICATOR AND EVALUATION MATRIX DEVELOPMENT RESULTS ....... 182	 ?5.2.1 Evaluation, indicators and concepts of ?success? ........................................ 183	 ?5.2.2 Paternalism, assumptions and participatory process................................... 186	 ?5.3 ETHNOGRAPHICALLY-INFORMED ANALYSIS OF INDICATOR DEVELOPMENT AND STAKEHOLDER PERCEPTIONS ...................................................................................... 192	 ?5.3.1 Principal component analysis and social dynamics ..................................... 193	 ?5.3.2 Hierarchical analysis and indicator matrix.................................................... 200	 ?5.4 PARTICIPATORY EVALUATION TOOL AND ITS APPLICATION ....................................... 205	 ?5.5 TOWARD EQUITABLE PARTICIPATION IN DENGUE POLICY: KNOWLEDGE TRANSLATION FOR EMANCIPATORY PRAXIS........................................................................................ 212	 ?5.6 RESULTS SUMMARY: EVALUATION, POWER AND TOOLS........................................... 216	 ?Chapter 6 ? Discussion & Conclusions .................................................................... 218	 ?6.1 WORLDVIEW, SOCIAL DETERMINATION AND KT....................................................... 218	 ?6.2 IMPLICATIONS OF RESULTS .................................................................................... 221	 ?6.2.1 Social dynamics and the Machala network.................................................. 223	 ?6.2.2 Participatory evaluation tool and KT model ................................................. 225	 ?6.2.3 Barriers to equitable participation in global health research ........................ 229	 ?6.3 STUDY STRENGTHS AND CHALLENGES ................................................................... 232	 ? viii 6.4 CONCLUSIONS AND NEXT STEPS ............................................................................ 235	 ?References................................................................................................................... 237	 ?Appendix 1 ? Excerpted EBS-Ecuador original project proposal .......................... 260	 ?Appendix 2 ? Key informant semi-structured interview guide and survey instruments ................................................................................................................. 279	 ?Appendix 3 ? Code book ............................................................................................ 288	 ?Appendix 4 ? Stakeholder Analysis Tables.............................................................. 302	 ?APPENDIX 4.1  ANALYSIS TABLE FOR STAKEHOLDER RELATIONSHIPS TO ONE ANOTHER AND TO THE PROBLEM OF PERSISTENTLY HIGH DENGUE INDICES.......................................... 302	 ?APPENDIX 4.2  ANALYSIS TABLE FOR STAKEHOLDER MOTIVATIONS AND IMPACTS OF THE PROPOSED COMMUNITY-BASED DENGUE PREVENTION AND CONTROL PROGRAM ........... 310	 ?APPENDIX 4.3  POLICY-IMPACT STAKEHOLDER ANALYSIS TABLES.................................. 318	 ?Appendix 5 ? Participatory indicator glossary......................................................... 334	 ?Appendix 6 ? Statistical output for principal component and hierarchical clustering analyses..................................................................................................... 349	 ?  ix List of Tables  Table 1 ? Comparison of knowledge translation models presented by Graham et al. (2006) and CIHR (2007) ..........................................................................34	 ?Table 2 ? Hierarchical organization of types of evidence ...................................38	 ?Table 3 ? Commonalities in evidence based practice and the CIHR knowledge translation model ..........................................................................................40	 ?Table 4 ? Overview of methodologies and timeline.............................................50	 ?Table 5 ? Principles of the Transformative-Emancipatory Perspective (TEP), the ecosystems approach to human health (EcoHealth) and community-based action research (CBAR) ...............................................................................54	 ?Table 6 ? Participant neighbourhoods with assigned cluster numbers and treatment randomization...............................................................................60	 ?Table 7 ? Stakeholder groups .............................................................................91	 ?Table 8 ? Degree and centrality for identified actors in the Machala Network ..143	 ?Table 9 ? Preliminary evaluation matrix ............................................................185	 ?Table 10 ? Kruskal-Wallis/Wilcoxon analyses with multiple comparisons for summed stakeholder responses to secondary level indicator groups ........187	 ?Table 11 ? Kruskal-Wallis/Wilcoxon analyses with multiple comparisons for stakeholder responses to tertiary level indicators.......................................188	 ?Table 12 ? Median likert responses to the community participation, empowerment and well-being survey .........................................................192	 ?Table 13 ? Principal component analysis output for tertiary-level indicators.....194	 ?Table 14 ? Distal tertiary-level indicators and their Eigen values for principal components 2 to 5 ......................................................................................198	 ?Table 15 ? Stakeholder group composition of respondents by cluster for Ward?s hierarchical clustering analysis ...................................................................202	 ?Table 16 ? Indicator groupings resulting from hierarchical cluster analysis ......203	 ?Table 17 ? Comparative evaluation outcomes for the EBS-Ecuador project proposed participatory dengue prevention and control program in early and final late stages, and the conventional program .........................................210	 ?Table 18 ? Comparison of the knowledge translation model outlined by Graham et al. (2006) and the Machala model for knowledge translation .................214	 ? x List of Figures  Figure 1 - Dengue virus transmission cycle ..........................................................2 Figure 2 - Aedes aegypti life-cycle .......................................................................3 Figure 3 - Iterative research/action loop proposed by EcoHealth. ......................28 Figure 4 - The EcoHealth analytic concept .........................................................29 Figure 5 ? Influence framework for ethnographically framed social network analysis.........................................................................................................69 Figure 6 ? Basic coding structure based on identified domains of interest and ethnographic observation .............................................................................78 Figure 7 ? a) Paternalism and powerlessness as determinants of health and b) the paternalism-powerlessness-disease cycle ...........................................129 Figure 8 ? Schematic of community-based dengue prevention and control social network in Machala.....................................................................................138 Figure 9 ? Betweenness centrality map of the Machala Network .....................140 Figure 10 ? Information network as it pertains to dengue and dengue services in Machala ......................................................................................................147 Figure 11 ? Dengue service provision network in Machala ..............................149 Figure 12 ? Ministry system policy network for dengue control in Machala......151 Figure 13 ? Municipal policy network for dengue control in Machala ...............152 Figure 14 ? Distribution of variables along the axes of principal components one through five.................................................................................................195 Figure 15 ? Health-impact evaluation model for integrated vector management strategies ....................................................................................................205 Figure 16 ? Evaluation tool for participatory dengue prevention and control programs in Machala ..................................................................................207 Figure 17 ? The Machala model for knowledge translation ..............................213 Figure 18 ? Incongruous worldviews influencing human health, well-being and security .......................................................................................................219 Figure 19 ? The dialectic relationship between social determination of health and knowledge translation.................................................................................227  xi List of Abbreviations BI:    Breteau index CBAR:   Community-based action research CIHR:  Canadian Institutes for Health Research COMBI:  Communication for behavioural impact social mobilization approach CoP: Community of practice CSDH:  The WHO Commission on the Social Determinants of Health DEN:   Dengue DENV:   Dengue virus DF:    Dengue fever DIT:    Roger?s diffusion of innovation theory DPSEEA:  WHO-developed framework based on Driving force, Pressure, State, Exposure, Effect, Action DSS:    Dengue shock syndrome EBP: Evidence-based practice EBS:  Eco-bio-Social approach to prevention and control of vector borne disease incorporating the analysis and addressing of ecological, biological and social risks and risk factors for vector-borne disease transmission through participatory strategy  EBS-Ecuador:  The Ecuador project "Meeting capacity-building and scale-up challenges to sustainably prevent dengue in Machala, Ecuador" as part of the TDR-IDRC multi-country study EBS-LAC:  The Latin America and Caribbean Eco-Bio-Social community of practice as it applies to the current EBS- LAC dengue and Chagas disease prevention and control projects funded by TDR-IDRC partnership  EcoHealth:   An ecosystems approach to human health EF:    Effectiveness EN:    Engagement facilitators  xii IDRC:  International Development Research Centre HI:    House index INSOC:   Social insertion index KT:   Knowledge Translation LAC:    The Latin America and the Caribbean WHO region MoH:    Ecuadorian Ministry of Health  MoE:    Ecuadorian Ministry of Environment  MoEd:   Ecuadorian Ministry of Education  ND:    Neglected disease NTD:    Neglected tropical disease OS:    Operational sustainability PC1-5:   Principal components one through five PCA:    Principal component analysis R&R:    Resilience and responsiveness SD:    Severe dengue SDH:    Social Determination of Health  SMCE:   Social multi-criteria evaluation SNEM:  Servicio Nacional de Eradicaci?n de Malaria (translation: National Malaria Eradication Service) is the vertical national vector control programme within the Ecuadorian Ministry of Health. Although the acronym persists as SNEM, this branch of the MoH has been aptly renamed Servicio Nacional del Control de Enfermedades Transmisibles por Vectores Artr?podos (translation: National Service for the control of Arthropod Vector-borne Diseases) TDR:  The UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training on Tropical Diseases TEP:    Transformative emancipatory paradigm UNICEF:   United Nations Children?s? Fund UNDP:   United Nations Development Programme UASB:   Universidad Andina Sim?n Bol?var   xiii UBC:    University of British Columbia  UTM:    Universidad T?cnica de Machala WHO:   World Health Organization  YFV:    Yellow fever virus  xiv Acknowledgements  First and foremost I extend a deep gratitude toward the 2000 families and other community members in Machala who graciously and generously opened their homes and their lives to me and to the possibility of forming relationships in hopes of earnest collaboration. Thank you in particular to Bismarck Pi?eda, Rodriguo Lozano, Jos? Palas, Vincenta Salinas, and Clorinda Loayza.  This work would not have been possible without the spirit of collaboration and welcome embodied by the research team in Machala. I thank them, beyond what can be expressed here, for their tenacity and dedication in the struggle for justice and health equity. Thank you to Dr. Efra?n Beltr?n Ayala, Dra. Ana Arichabala Wilches, Tania Ord??ez Le?n, Jefferson Adrian Delgado, Dra. Mercy Silva Bravo, Dr. Julio Palomeque, Dr. Alvaro Calle Le?n, Zaida Ord??ez Gallegos, Wilson Pe?a Ortiz, Mariuxi Guerrero, Patricia Zhinin, Marcelo Chimbo, Lorena Fabre Salvatore and Franklin Ruiz.  Thank you to the team at Universidad Andina Sim?n Bol?var for their inspired work with social determination and critical epidemiology, for pushing the agenda of Buen Vivir into the spaces of research, policy, programs and practice, and for allowing me to learn and work with them. Thank you to Dr. Jaime Breilh Paz y Mino, Mar?a Jos? Breilh Ayora, Ylonka Tiller?a, Bayron Torres, Mar?a Luisa Espinoza, Sonia Figueroa, Monica Izurieta and Dr. Enrique Ayala Mora.   Somehow, the stars aligned in my luxurious favour to grant me the blessing of the most supportive and genuinely thoughtful supervisory committee I could have hoped for. It was indeed a pleasure and a challenge to work with the brilliant minds, open hearts and skilled hands of this group of amazing researchers and all-around admirable people. Thank you to Drs. Jerry Spiegel, Muhammad  xv Morshed, Bonnie Henry and Alejandro Rojas. Thank you also to Robert Balshaw for his advice and guidance on statistical analyses.  The rare and beautiful opportunity to truly shape the research discussed in this thesis was afforded to me by the Interdisciplinary Studies Graduate Program, for which I am profoundly grateful. Thank you to Dr. John Beatty, the chair under whom I was admitted on faith more than funding, and thank you to Dr. Hillel Goelman, the chair under whom I will defend this work. This program is a gift to the academic community, and hopefully through the innovation it demands, will bring the larger gift of interdisciplinarity to greater causes. Thank you to the Canadian Institutes for Health Research for awarding me the Frederick Banting & Charles Best Doctoral Fellowship that supported three of the five years of this work.  Thank you to my family and friends for their encouragement and undying belief in me over the past 5 years and beyond. I am a better human being for the gentle and constant influence your love has in my life; you have all helped me to navigate life, stay humble, maintain my integrity and encouraged me to push my own limits. Hugs, kisses and thank-yous to my wife, my parents, my sister, Dan, Kira, Jake, Jan, Alice & Bill, Ben Brisbois, Dawn Cooper, Uncle Kevin, Uncle Guy, Auntie Enid, Gaetane, Eric, Amma, Auntie Kathy, Alanna & Adam, Zen, Jai, Cole, Rhoda & Jes?s, Ruth, Valerie Alberts, Andrea Taylor, Jens & Silvia, Kathryn Ransdell, Tim Scorer, Gary Paterson, Lorna Seaman, Jimmy Baldwin, Don Amero, and Shirley Etter.   xvi Dedication  This thesis is dedicated to God and to my wife, Sheona Mitchell-Foster, without whom the pastures would not have been so green, the waters not as calm, and darkness of the valley far more fearsome; the three-strand cord is not easily broken.  1 Chapter 1 - Introduction to the Study  1.1 Setting the scene This dissertation explores how knowledge management strategies and socio-political systems affect the accessibility and application of rich, multi-faceted evidence to improve the health of socially and politically disempowered groups of people.  Since the Alma Ata declaration in 1978, definitions of health have moved beyond a basic understanding of health as an absence of disease toward a holistic conception that includes social, cultural, political, environmental, biological and spiritual elements [1-7]. Newer paradigms and approaches to human health research and addressing complex related health issues at the individual, community and population levels have emerged to accommodate these broader definitions. One-Health, EcoHealth, Eco-Bio-Social, community-based action research, evidence-based public health and the DPSEEA framework guide investigation into the nature of the relationships between human health, non-medical determinants and global-level social and economic forces like globalization [8]. Such inclusive concepts of human health have precipitated a call for equally holistic and interdisciplinary methodologies, programs, policy and communities of practice. Interdisciplinarity presents a particular opportunity to bring together expertise from disparate fields to address complex health issues, developing new strategies based on the varied experiences, capacities and kinds of knowledge pertinent to each discipline [9-11]. A main challenge to interdisciplinary research and collaboration, however, remains building bridges between disciplinary silos and community to make  knowledge from each group accessible to one another, and move knowledge and research to action [9, 12].  Dengue virus (DENV), and the febrile diseases it causes, provides a particularly vivid example of a human health condition intricately linked to biological, environmental, social and political systems that requires interdisciplinary thinking  2 and intersectoral collaboration to find sustainable strategies to reduce, if not prevent, the negative impact of the disease [13, 14]. Infection with DENV in humans results in a spectrum of illness dependent on virological, immunological, physiological and environmental factors. Symptoms can range from subclinical or a mild febrile illness to classical dengue fever (DF) to the more serious and often fatal severe dengue (SD) and dengue shock syndrome [15-21]. Dengue virus is a single-stranded positive-sense RNA virus, of which four human serotypes exist (DENV1-4) [15, 21, 22]. All human sertoypes of DENV are maintained and spread via a direct human-mosquito transmission cycle (Figure 1) with the principal vector being Aedes aegypti and the secondary but increasingly important vector Ae. albopictus.     Figure 1 - Dengue virus transmission cycle  Aedes aegypti is a peridomestic anthrophilic mosquito that thrives in urban and peri-urban settings. This mosquito is so well adapted to living among humans, it nearly exclusively feeds on human blood and preferentially oviposits in confined water containers associated with human activity and is often found immediately around or inside human dwellings [21, 23-25]. Aedes aegypti has a holometabolous life cycle with an egg stage followed by four aquatic larval instars, an aquatic pupal instar and a free-flying terrestrial adult stage that emerges from the containers into the domestic or peri-domestic environment to seek blood hosts (Figure 2). Both the number of hosts that an infected mosquito bites and the spatial association between these hosts can affect the DF/SD  3 incidence during either endemic or epidemic DENV transmission. The more human hosts an infected mosquito probes to complete her bloodmeal, the greater the incidence of DF that can be attributed to her; on a population level, this aspect of Ae. aegypti biology carries epidemiological significance [26].         Figure 2 - Aedes aegypti life-cycle [27]   Neighbourhoods marked by sub-standard housing and densely populated with people susceptible to circulating DENV serotypes are considered at high dengue transmission risk especially when residents intentionally store water due to lack of running water, or where water accumulates in containers due to lack of sanitary infrastructure and garbage collection services [13]. Accordingly, issues of housing, provision of basic services and sanitary infrastructure, vector ecology, human population density, accessibility of health services and human behaviour combine under the driving forces of globalization and poverty to create an environment conducive to dengue transmission. Interdisciplinary strategies and interventions addressing issues ranging from land-use, water stewardship, public works, governance at multiple levels, vector ecology, social determinants of health, education, solid waste management, environmental management, clinical management and curative health services, health promotion and preventive  4 health programs, human security and political agency are thus needed. This requires significant effort to build intersectoral spaces, foster equitable intersectoral collaboration and to share, mobilize and implement evidenced and tacit knowledge [28]. Community participation is widely accepted to be a crucial element in determining the success and sustainability of interdisciplinary dengue prevention programs [13, 21, 29-32].   Building on circumstances where knowledge about health conditions and the factors that affect them is continuously expanding, Knowledge Translation (KT) has been receiving growing attention as a conceptual framework for understanding and guiding how some of the major challenges to interdisciplinarity may be addressed [33-35]. Indeed with varying degrees of success, KT has been and continues to be implemented as a means to strengthen intersectoral spaces, facilitate collaboration and improve the translation of research results to health impacts [36]. KT is increasingly popular in the field of global health and due to its applied nature has been adapted for use in participatory research. Recognition of the importance of evaluation is implicit in the cyclic process of KT, i.e. with respect to evaluation of available knowledge, supportive and antagonistic forces influencing its use, needs of information users, uptake of knowledge and impact of knowledge use as it pertains to an identified issue [34, 37].  KT and evaluation within the scope of interdisciplinary communities of practice and intersectoral collaboration should be inclusive to a wide range of knowledge and serve to facilitate innovation through equitable participation.   Importantly, KT should be contrasted with knowledge management, understood for the purposes of this dissertation to be institutional strategies for the use, cultivation, application and leveraging of possessed knowledge assets in the form of people, knowledge products, and/or technology, to fulfill institutional mandates, improve outputs, and/or achieve a competitive edge [38-41]. In this sense, KT as a process that can be engaged to promote and sustain  5 intersectoral, transdisiplinary and community-based health endeavours (see section 2.4 of this thesis), interfaces with the siloed and mandated knowledge management strategies of the institutions and sectors that it seeks to bridge.   It is on the basis of the perspectives discussed above that I sought to investigate the processes whereby appropriate knowledge could be generated to most effectively engage those with a stake in its application, by considering a global public health challenge that provided a fitting opportunity for this examination.  1.2 An international effort to strengthen dengue prevention and control Dengue fever is the most important viral mosquito-borne disease worldwide and is increasing in geographic range and incidence at an alarming rate [13, 21, 42]. An emerging and re-emerging infectious disease, nearly half the world?s population (approximately 2 billion people) is estimated to be at risk for dengue infection, with the majority of this susceptible population in lower and middle-income countries [42-44]. Declared a ?public health emergency of international concern? in 2005 by the 58th World Health Assembly, the dengue fever annual incidence rate is between 2.5 and 5% of the at-risk population resulting in approximately 50 ? 100 million cases and 20 000 deaths annually [21, 42-45].   Despite its global relevance, dengue fever (DF) has been classified as a neglected disease (or neglected tropical disease ? NTD) by the World Health Organization (WHO) and shares this designation with 16 other diseases (Chagas? disease, leprosy, leishmaniasis, onchocerciasis, dracunculiasis, schistosomiasis, lymphatic filariasis, trachoma, African trypanosomiasis, treponematoses, rabies, Buruli ulcer, cysticercosis, food-borne trematode infections, echinococcosus, soil-transmitted helminthiases) [46-48]. Neglected diseases are described as diseases of poverty, affecting the world?s poorest and most marginalized one billion people; diseases that have been and continue to  6 be neglected by research and that can be prevented or cured with relatively simple interventions [46-50]. These ?bottom billion? live in the world?s most economically stressed, population-dense, environmentally degraded areas of the world that are generally underserviced by health systems and infrastructure; a perfect storm for the epidemic spread of dengue to new human populations and geographic areas (emerging infectious disease) and for increasing incidence, prevalence and frequency of outbreaks in already endemic areas (re-emerging infectious disease) [15, 49, 51].  Because of its NTD status, DF falls under the research and development umbrella of the Special Programme for Research and Training on Diseases of Poverty (TDR) funded by the World Bank, UNDP, UNICEF and WHO.  Large-scale initiatives within TDR have been created and undertaken with the singular focus of dengue: a Scientific Working Group was created to address dengue in the WHO South East Asia Region, a current joint initiative between the International Development Research Centre of Canada (IDRC) and TDR is addressing dengue in the WHO Latin America and Caribbean Region, TDR Business Line 5 for Innovative Vector Control Interventions also supports a number of dengue prevention and control projects [21, 52, 53].  The three-year project ?Meeting capacity-building and scaling-up challenges to sustainably prevent and control dengue in Machala, Ecuador? was funded in 2010 by the TDR-IDRC research initiative on Innovative Community-based Ecosystem Management Interventions for Improved Dengue and Chagas Disease Prevention in Latin America and the Caribbean. This project is part of a larger effort within TDR to support the use and further the development of the Eco-Bio-Social (EBS) approach to vector-borne disease prevention through establishing a multi-country community of practice in the Americas. The joint Ecuador-based project is a comparative study that uses a randomized-controlled cluster trial to evaluate two different approaches to dengue control programming in Machala: a participatory approach to dengue prevention focused on education,  7 vector breeding source elimination and community involvement is compared with a reactive, insecticide-based program. The current EBS-Ecuador project is based on two successful pilot studies and represents a second step in the scaling-up process of participatory dengue prevention strategies in Machala. It therefore holds an overarching objective to investigate the effectiveness and feasibility of applying an ecosystem approach to prevent and control dengue and facilitating its scale-up to the civic level in a vulnerable endemic setting marked by infrastructural weaknesses and recent large-scale outbreaks and epidemics [54].  EcoHealth, EBS and other integrative participatory approaches allow interdisciplinary and intersectoral teams to develop innovative solutions to local problems that are often just as effective, or more so, than conventional solutions. A major criticism, however, is that these projects and outcomes are only relevant to the local (specific) context in which they were developed [55, 56] Scaling-up local success with participatory and community-based dengue prevention programs poses significant challenges with changing contexts specific to neighbourhoods, sectors, districts, municipalities, provincial and national geographies. This complicated process requires inventive KT strategies to support stakeholders in integrating knowledge from unfamiliar disciplines, sectors, fields of expertise and personal experiences in order to make decisions.   1.3 Research problem and research questions The effects of social determinants of health and macro-scale phenomena, such as globalization and urbanization, on dengue and other neglected diseases have been explored by researchers as crucial to understanding and addressing the persistence and re-emergence of many neglected diseases in low-resource settings [57, 58]. The WHO Commission on the Social Determinants of Health (CSDH) represented both a culmination of years of increasing interest and work in these areas, and a turning point in the mainstreaming of these ideas and approaches [59]. The CSDH report was also a call to action on the part of researchers, funders and government entities to implement projects and  8 programs to promote health equity on a large scale. In this respect, the role of social science and qualitative research in addressing health equity and neglected diseases has been solidly established, even within the relatively restrictive conception of causal pathways in mainstream epidemiological theory and practice. The disciplines of social and critical epidemiology, most prominently developed and practiced in Latin America, present a stronger and more clearly articulated challenge to these linear relationships of causation that systematically exclude considerations for production of health and harm through the effects of social, political and economic structures on quality of life and well-being of individuals, communities and populations [60, 61].   Addressing systemic barriers and bridges to health equity and neglected disease prevention and control without a clear understanding of the complexity of social, ecological and political environments at the local level may negatively affect the sustainability, appropriateness and effectiveness of interventions [58]. There is a historical lack of focus on exploring the connections between the individual, household, community and governmental social spheres, and how the complexity of those connections affects the process of addressing health issues within the current public and global health paradigm [57, 62]. We ought to explore the different relationships, contexts and dynamics particular to each stage of this process, from problem definition, to program design, implementation, evaluation, and scaling-up of successful interventions [63, 64]. Scale-up efforts of local successes in EcoHealth-style interventions are often frustrated because of timelines and funding insufficient to support this kind of qualitative social research necessary to support the development of KT models and guiding principles for participatory practice [65]. This study begins with the broad objective of better understanding the social, cultural and political context of participatory dengue prevention and control programs in Machala and how each of those contexts may influence evaluation, knowledge translation and research-to-policy processes.   9 The overarching goal of the EBS-Ecuador project to ?meet capacity-building and scale-up challenges? in the context of participatory dengue prevention in Machala, fully acknowledges that there are challenges to the operationalization and institutionalization of EBS and EcoHealth-style public health initiatives. Further, these challenges are particular to time, place and space, and require attention to maintain integrity and effectiveness of already established, local, smaller-scale success over extended temporal and geopolitical scales. In order to meet the challenges, they must be situated within the particularities of social, political, cultural and economic dynamics that determine their nature. This thesis thus aims to shed light on some of these dynamics and their complexities in the context of dengue in Machala; to propose tools intended to facilitate the consideration of the same dynamics through current and future implementation, evaluation and scale-up cycles as they pertain to community-based dengue prevention and control; and on this basis, to consider opportunities for further reflection and investigation. In this regard, the wider research question that I address can be characterized as follows: How do current knowledge management strategies limit equitable participation and where are there opportunities to change?  To investigate this proposition, the specific research questions adopted in this study were:  1) Who are the stakeholders involved in and affected by participatory dengue prevention and control programs in Machala and how do they interact within that context? 2) How do the interactions between stakeholder groups and the perceptions they have of one another affect evaluation, knowledge translation and research-to-policy processes?  3) Are new tools, strategies and models required to support more equitable evaluation and knowledge translation processes? If so, what do they look like? 1.4 Significance of the study This study intends to provide insight into the social, cultural and political context of participatory dengue prevention and control programs in Machala through participatory  10 process. There is significant theoretical emphasis on the importance of social determinants of health, however, practical considerations for investigating social factors contributing to the persistence and resurgence of neglected diseases still lags [66]. This work seeks to emphasize the transformative potential of investing earnestly in social science research as part of a more holistic approach to addressing challenges in dengue prevention. Rather than an ?added value? aspect, social sciences research exploring specific contexts that produce dengue risk should be an integral element that drives, along with ecological and biological elements, the research to policy process, program design, implementation and evaluation. This study carries implications, both theoretical and practical, for knowledge translation with respect to community health and neglected diseases, and for participatory evaluation praxis.  In particular, the research described in this thesis serves as a practical step in a larger feasibility and scale-up study. The scope of this research is specific to supporting the scaling-up process of the EBS-Ecuador project in devising knowledge translation strategies and evaluation tools that reflect the experiences, concerns and goals of involved stakeholders; it is not intended to assess or document the evaluation and scaling-up processes themselves. The methods, results and outputs provide a working example of participatory process facilitating the systematic inclusion of experiential and tacit knowledge alongside technical and quantitative knowledge, enabling the integration of strong focus on exploring social determinants of dengue transmission risk into the overall research-to-policy process. The methods and findings of this thesis also challenge the accepted decision-making hierarchies of research and policy. Invoking the principles of participatory action research, social justice and health as a human right calls into question the power imbalance with respect to agenda setting, budgeting, timelines and knowledge valuation schemes. 1.5 Overview and organization of the thesis The organization of this thesis reflects the participatory nature of the research it describes; theories, methodology and results evolve through a spiral of collaborative exploration of issues and challenges as they pertain to the evaluation and scale-up of participatory dengue prevention and control programs  11 in Machala, Ecuador. Building from the experiences of the pilot projects, this thesis intends to address the research problem and research questions identified in section 1.3.   Chapter 2 provides theoretical framing and general context for chosen methods and study design. Dengue fever, its persistence, resurgence and changing epidemiology in Ecuador provide the overarching impetus for this study. The history of dengue transmission in Latin America and Ecuador offers insight into biological, ecological and social factors that determine current dengue risk and transmission in Machala. An examination of the literature on social determinants of health lays a foundation for the importance of inclusion of social analysis and social science in health research, particularly for neglected diseases as illustrated by the case of dengue. Reviews of the theoretical underpinnings and literature on EcoHealth and Eco-Bio-Social approaches, knowledge translation and participatory indicator development frame the methodological decisions and discussion in Chapter 3.   Chapter 3 of this thesis provides a more focused overview of chosen methodologies and their appropriateness with specific reference to undertaking research on dengue participatory dengue prevention and control programs in Machala, Ecuador. Mixed methods provide a pragmatic overall approach to the design of a methodology that is rigorous without being exclusive; combining quantitative and qualitative data collection and analysis methods has facilitated the more nuanced ways of understanding, exploring and working within the complex issues, dynamics and relationships related to this research. A focus on equitable participation and the social determinants of health demands intentional consideration of the local context as an axis around which methodological development should revolve. Ethnography and interpretivist inquiry are the underlying drivers for the more specific social analysis and participatory indicator development methods. Ethnographic observation, meetings, interviews, focus groups, surveys, questionnaires, and both qualitative and quantitative analyses  12 are laid out as the plan to address the research questions described in section 1.3.  Chapter 4 addresses the specific research question regarding the identification of involved and affected stakeholders, and how they are connected to and interact with one another. I explore the social network as it pertains to participatory dengue prevention and control in Machala, as well as some of the social and cultural dynamics that affect the relationships between stakeholders in that network. The social network map and analyses paint an overall picture of the structure of the network as well as of stakeholder relationships. The results presented in this chapter also begin to address the second specific research regarding how the attributes or qualities of the interactions between stakeholder groups and the perceptions they have of one another affect processes related to participatory dengue prevention and control in Machala. The character of the network and of identified relationships are contextualized through illustrative vignettes that describe the complex nature of negotiating equitable participatory work with diverse stakeholder groups in a setting marked with restricted resources, patchy infrastructure and intense public health burdens. These findings inform the participatory indicator development process described and discussed in the next chapter.  Chapter 5 focuses on evaluation strategies and tools with the objective of supporting the EBS-Ecuador project in its policy recommendation and scale-up process. Building on the findings of Chapter 4, the results presented in this chapter continue to explore the ways that stakeholder interactions and perceptions influence evaluation, knowledge translation and carry implications for anticipated scale-up processes. Participatory indicator development combined with principal component and hierarchical clustering analyses are used to develop an evaluation tool, which is proposed and explored in the context of comparatively evaluating two treatments in the EBS-Ecuador project. The development of this new tool and a guiding KT model address the third specific  13 research question regarding the potential need for new tools that facilitate more equitable KT and evaluation processes. The KT model is constructed based on the combined findings of the social network analysis, ethnographic observations, and its employment in the research-to-policy process and the international global health research system.   Chapter 6 summarizes the arguments and findings of this thesis and explores their implications for dengue prevention and control research, programs and policy. I then use these findings and the implications they carry to challenge current macro, mid and local level knowledge management strategies. Opportunities for improved equity in knowledge valuation schemes, KT and evaluation processes, as well as anticipated scale-up, policy-recommendation and policy-making processes may exist at the interface of equitable knowledge translation and social determination.  14 Chapter 2 ? Foundations of the Study Dengue fever as a vector-borne viral disease is a human health problem situated at the interface of social, ecological, biological, political and historical forces. This chapter explores some of the history and narrative of the emergence and re-emergence of dengue virus transmission in the social, political and ecological context of Latin America and specifically, in Machala, Ecuador. Importantly, the specific experience of dengue in Machala is a product of local, regional and global forces alike; the latter half of this chapter explores the nature of these forces and proposes the application theoretical frames, research approaches and methodological processes useful to working with and addressing them. 2.1 Dengue fever in Latin America Genetic marker analyses of pupae and larvae in domestic containers as well as dispersal studies have shown that, although it is capable of traveling longer distances, Ae. aegypti mosquitoes rarely feed or oviposit further than 150 m from the site of adult emergence, often returning to that same site and surrounding sites [23, 67, 68]. Scarcity of oviposition sites drives gravid Ae. aegypti mosquitoes to disperse greater distances to lay their eggs, however, they always remain inextricably linked to human populations and human migration patterns [69]. The movement of people and goods globally coupled with the close association of Ae. aegypti to human populations have facilitated emergence and resurgence of DENV worldwide [70, 71].  As the global incidence of severe dengue increased during and just after WWII, political will and funding were focused on Ae. aegypti eradication campaigns. These campaigns were launched largely in response to epidemics of Yellow fever, but because Ae. aegypti transmits both dengue virus (DENV) and yellow fever virus (YFV) (closely related flaviviruses) they were effective against dengue as well [44, 72-74]. Vector control programs of this era were vertical in nature and mainly depended on spraying insecticides such as DDT into the homes and  15 environment of the affected human populations. These efforts in the Americas were initially very successful in reducing vector populations and interrupting DENV and YFV transmission. Many countries in the Americas officially proclaimed they had eradicated the Ae. aegypti vector within their borders [75, 76]. As a result of their success, the programs in the Americas were thought to have become redundant and disintegrated through neglect or were eliminated by governments in the 1970s [72, 77]. In addition, DDT was banned in the United States of America in 1972 removing political and legal support for these campaigns [77]. By 2001, Ae. aegypti had re-invaded geographic areas it had historically inhabited and had spread into new geographic areas [44, 72-74, 78-80]. This explosive re-emergence of dengue and dengue vectors in the Americas, the result of dependence on defunct state-driven vertical programs, has motivated the current conscious shift in prevention and control strategy toward community-based and/or participatory programs [43, 70].  Locations that have thriving and growing vector populations also have thriving and growing viral transmission [72]. The 1980s brought explosive outbreaks and epidemic spread of dengue throughout the Americas, the number of countries reporting DENV cases worldwide grew to over 100 from 9 in the 1950s [72, 80-82].  Dengue had been commonly accepted as a childhood illness in Southeast Asia since before WWII, but the resurgence of DENV has seen it become a leading cause of childhood mortality in both Southeast Asia and the Americas [72, 73, 80, 83, 84]. Although DENV is endemic in Africa, African DF/SD epidemics are reported far less frequently. This is likely due to poor DENV surveillance, lack of accessible laboratory testing, and reporting in the area as well as a large burden of other diseases, particularly malaria, that often take precedence in the African context and is perhaps not indicative of lower DENV transmission in the region [71].  In the Americas, a DENV-1 pandemic occurred from 1977-1980. The over 700 000 reported cases of DF were distributed throughout the Caribbean, Northern  16 South America and Mexico. The arrival of DENV-2 caused a SD outbreak in Cuba in 1981, whereas DENV-3 disappeared from the Americas in the late 1970s only to reappear again in 1994. DENV-4 was also introduced to the region via the Caribbean in 1981 and quickly spread throughout the area [73, 80, 85]. The rapid emergence of DENV and hyperendemicity in the Americas has resulted in a changing DF/SD epidemiology, and has brought attention to the changes in its epidemiology worldwide. DF and SD are primarily diseases of adults in the Americas whereas they have traditionally been considered pediatric diseases in Southeast Asia [86]. All four serotypes have been found in Southeast Asia since they were first isolated and identified during World War Two, and as a result it was believed that the epidemiological patterns for DF/SD were stable in this region. More recently an increasing proportion of reported cases in both Southeast Asia and the Americas are afflicted adults [80, 84]. The improved clinical definitions of DF, SD and DSS as well as improved diagnostics, surveillance through public health systems and primary care delivery for infected persons may be playing a role in the increased number of reported cases in adults. DF/SD are difficult to distinguish from other febrile illnesses where a lack of resources restricts technical diagnostic capacity and the historical emphasis on hemorrhagic symptoms to diagnose SD resulted in skewed clinical surveillance [87].   Global and regional-scale serotype emergence and vector infestation do not relay the more nuanced experiences of populations affected by this emerging and resurging disease within regions. Dengue incidence continues to rise within regions and new countries and geographical units within countries continue to report first cases and first epidemics of DF/SD [86]. Bhutan reported its first cases of DENV infection in 2005, Nepal?s first DF outbreak was reported in 2006; North Korea is the only country in the WHO Southeast Asia region (SEA) not reporting indigenous DENV transmission [86].  The first outbreak of DF caused by indigenous DENV transmission in Chile was reported in 2002, DENV-1 was isolated from the patients [88]. DF/SD outbreaks/epidemics in both regions follow  17 a cyclic pattern of outbreaks every few years involving thousands of people with lower-level endemic transmission sandwiched between. An alarming pattern has been documented in the Americas whereby DF epidemics are followed by a three to four year low-level endemic transmission period that leads into a 2-3 year epidemic transmission period. Of particular concern is the escalating severity of the 2-3 year epidemic periods, progressively higher incidence has been observed in latter cycles [89]. Epidemics normally originate in large urban centres marked by high human population density and weak public infrastructure (sanitation services, reliable municipal piped-water supply) and spread outward to smaller centres [86].  2.1.1 Dengue in Ecuador Globalization has had profound effects on Ecuador in terms of industry, agriculture, human and environmental health, and political, social and health systems [70, 90].  Weak health and social systems in Ecuador are continually eroded by the influence of structural adjustments imposed by the crushing debt the country carries to the International Monetary Fund (IMF) [90, 91]. In a country where glaring health and economic inequity exist, neo-liberalist trends in policy and programming have led to increased rural poverty, progressively poorer access to health care and environmental degradation which has, in turn, contributed to urbanization.   Ecuador?s history of epidemic yellow fever led to participation in the widespread Ae. aegypti eradication campaigns and the elimination of the vector in 1958 [91]. The resurgence of the vector has allowed DF to emerge as a major public health issue in Ecuador along with other vector-borne diseases. Today, Ecuador is endemic for DENV-1, 2 and 4 with its first outbreak of DF in 1988. Over 800 000 people were affected by the DENV-1 epidemic in Guayaquil, epidemic cycles continued throughout the 1990s and through the early 2000s registering approximately 3 million cases to date [92]. An outbreak of DF/SD occurred in 2003 with 10 726 cases of DF and 206 of SD [92]. In 2010 there was a dengue  18 epidemic in El Oro from mid-January to April with 3365 cases of classic dengue fever and dengue hemorrhagic fever. Machala proper registered 1474 dengue cases. Pasaje, Guabo and Santa Rosa, all within 20 minutes of Machala, registered a combined 1408 classic dengue cases [91]. Ecuador has seen a steep increase in the overall number of dengue cases over the past few decades [54]. The epidemiology, geographic distribution and seasonality of dengue are changing through ecological and climatological effects on vector populations [93-95]. Links between climate change and vector-borne disease in Ecuador have emerged as priorities for government programming and investigation as well as government-university research partnerships [96]. While cases and outbreaks of DF/SD are anticipated in the larger coastal urban and peri-urban areas of Machala (El Oro), Guayaquil (Guayas) and Huaquillas (El Oro), cases of DF are now being found in the smaller cities of Zaruma and Portovelo in southern highlands of El Oro that were previously considered outside the ecological and geographic region of Ae. aegypti [94].  Vector control in Ecuador is done through a vertical body of the federal government, the National Service for Control of Vector-borne Disease (SNEM), and is primarily an insecticide-based responsive control program based on epidemiological and entomological data. As cases of DF/SD are identified by the primary health care system, epidemiological data is transferred to the vector control branch that dispatches a fumigation team to the residence of the reported case. Inspection for larvae, pupae and adults on the premises is done, indices are recorded and the interior, exterior and surrounding grounds of the house are sprayed with insecticide and larvicide is used to control standing water. Depending on seasonality and measured DENV transmission risk, the surrounding houses and their grounds are also sprayed with insecticide [94]. This vector control program is linked strongly with the primary health care system and with health promotion activities within the decentralized health units. Social mobilization is used often and is effective in improving health outcomes and positively impacting risks for many different diseases [97, 98].   19  Ecuador suffers from a shortage of skilled human resources for health and research capacity. Weaknesses in health systems and the capacity to evaluate programs and generate innovative vector control strategies have been targeted by recent efforts to build health research capacity and to empower communities to become involved in health training and decision-making [97, 99, 100]. These projects have helped to introduce the new paradigm of EcoHealth; a focus on human health as the product of the environment, social and political structures that one lives within and of human behaviour [101]. This new capacity for vector-borne disease prevention and control research with the new focus of EcoHealth is accordingly well positioned to facilitate a social-ecological approach to vector control innovation [58, 99, 100, 102, 103]. By linking with the established and ongoing achievements of the Latin American ?salud colectiva? initiative, such pursuits can be especially sensitive to considerations of health equity in conditions of great disparities [101].   These new trends in developing capacity in health research and strengthening health systems are opportune in that they coincide with a change in political will in Ecuador. The ratification of the New Constitution of Ecuador in 2008 has created a shift in priorities toward placing more importance on human health, quality of life and the health of the natural world (Pachamama) [60, 104]. Ecuador has opened a policy window in which political support and attention are currently focused to a far greater extent on non-medical factors that affect health; environmental degradation, education, health systems, human rights, food and water security.   The challenge to Ecuador in the domain of dengue is well illustrated by the relatively successful examples of Cuba and Thailand that feature intersectorality and a focus on social determinants of dengue transmission risk [14, 105-111]. Cuba, on the other hand, has had impressive successes when dealing with both epidemic and endemic DENV transmission. This has been attributed to the  20 overarching focus that the Cuban government has maintained on improving health for over 50 years and, as products of that focus, an incredible wealth of skilled human resources in health, strong and integrated health systems, great health research capacity and decentralized health service delivery systems that focus on social mobilization [112-115]. Even with limited economic resources, Cuba has been able to successfully manage DF/SD within its borders by implementing Cuban-style integrated vector management and promoting community ownership of DENV environmental risk management [116]. Thailand has strong primary health care and reporting systems backed up by a robust diagnostic infrastructure with links to military institutions and research [106, 117]. This electronic reporting system is housed within the Division of Epidemiology of the Ministry of Public health relays information about DF/SD cases directly from patient records to epidemiological databases for analysis and dissemination of information through the Thai Ministry of Public Health [107]. Recent IVM projects with community involvement in implementation are based directly on the results of in-country research on the changing epidemiology of DF/SD, and showing that school-aged children are the most important age group for SD in Thailand, insecticide resistance is reducing the effectiveness of chemical-based prevention, the need for a social-ecological component in DENV control programs and that epidemics occur during the rainy season [106-108]. This uptake of evidence and implementation of recommended solutions has shown reduced vector indices and incidence of DF/SD in treatment areas as compared to control [118]. An even more recent multi-country study, which included a Thailand-based study, has shown that interventions with ecological, biological and social components are far more effective at reducing DENV transmission and risk than those without [108, 119]. Integrated vector management should be incorporated as part of an intersectoral effort to combat dengue through the reduction and/or elimination of environmental and social DENV transmission risks [120]. Focusing on the already established strength for social mobilization, Ecuador is pushing toward social empowerment through training and capacity building for a genuinely bottom-up and participatory evidence generating process  21 [30, 99, 100]. It remains to be seen whether the policy window has opened wide enough or will stay open long enough for this burgeoning body of in-country research to affect vector control policy and program implementation.  2.2 Social determinants and social determination of health Definitions of health have moved from a static biomedical idea focused on the presence or absence of a disease in the human body, to a systems-based concept including the production of health through systems and forces that act on and interact with human populations. This systems vision stresses the importance of examining upstream influences on health; global, macro, regional and local forces determine the context for human health at various levels through the influence of political, social, cultural, economic, environmental and resource systems [104, 121]. Social determinants of health (SDH) have become more prominent in public health, international health and global health research following the publication of the Report of the WHO Commission on Social Determinants of Health in 2008, which describes and examines SDH within the frame of social justice, health inequity and health as a human right [122, 123]. Evidence abounds that impoverished, marginalized and stigmatized populations have lower health indicators, lower quality of life, higher morbidity and mortality than populations who enjoy at least the basics of human security, a higher socioeconomic status, and higher political and social agency. Unfortunately, increased evidence and awareness of SDH have not necessarily translated to advances in addressing them through policy mechanisms [59].   The social justice frame drawn around these health inequities, interrogates the static concepts of poverty, stigma and marginalization. Rather than understanding these immensely complex dynamics as labels or fixed qualities of populations, they should be considered as mechanisms through which oppressive systems deprive human beings, both individuals and communities, of their basic human right to health. Health inequities are created by the disproportionate allocation of resources, power, services, security and agency  22 that pervades nearly every level of human organization. Global trends in health inequity are replicated at the regional, national, state and municipal levels all over the world; policies and programs at every level participate in the creation or determination of structures and circumstances that damage the health of human beings. The Commission on Social Determinants of Health outlines three principles of action to improving health equity through addressing SDH: improving the conditions of daily life, confronting and changing the systems that produce and perpetuate the unequal distribution of resources, power and services, and creating skilled human resource capacity to address SDH through action, monitoring, reporting, awareness and sustainable change. These gargantuan tasks carry the weight of hundreds of millions of people. Reference to neglected diseases and marginalized people is increasingly frequent in global health rhetoric, as is work centered around ?the bottom billion?, which as discussed in the Introduction, highlights the desperate and urgent situation that continues to intensify through neoliberalist and extractive policies still relied upon to drive trade, economic growth, land-use and service provision world-wide.       Undertaking research and development works focused on SDH adds the dimension of social justice to the design, execution and evaluation processes for new health interventions. Holding an overarching and long-term goal of improving health equity is important to the necessary reorientation away from short-term easily measurable outcomes and deliverables, and toward a less immediate, difficult to measure, but perhaps infinitely more valuable social change at multiple levels of human organization and governance. This may imply a re-definition of success, objectives and timelines; rather than short-term, superficial interventions, we ought to be working toward comprehensive interventions that address the policies programs and practices of all sectors that converge to produce and sustain complex human health issues. Working toward health equity through addressing SDH should include, regardless of the issue at hand, considerations for examining governance, power dynamics, human security and political agency of affected people and addressing upstream inequities in the  23 distribution of power, resources and services that contribute to local problems. This work should be action-oriented; rather than producing evidence to be ?taken up? by decision-makers that are steeped in oppressive policies and systems that perpetuate inequity, evidence must be generated in an equitable way such that it may be brought to bear on political processes, governance and decision-making.   Frameworks such as the WHO-developed DPSEEA (Driving force, Pressure, State, Exposure, Effect, Action) framework help to clarify the scope of health issues and provide a working context for such interventions [121, 124]. Driving forces are macro-level dynamics (policies, globalization, industrial trends) that produce specific pressures on physical, social, political or cultural environments (patchy basic and sanitary infrastructure, rapid urbanization, use of plastic packaging), which in turn create a particular state of being or context for a health issue (stored water for domestic use, peri-urban poverty and sub-standard housing, environmental pollution with plastic containers). The interface of daily human existence with the macro-level forces is explored through exposure to a health risk (Ae. aegypti production within the home, lack of physical barriers between infected dengue vectors and susceptible people, abundance of vector breeding habitat in the community space), and effect explores the immediate experience of illness or damaged health of affected people (high dengue transmission risk, vector indices, and dengue incidence).   The vision of the DPSEEA framework specifically encourages consideration of possible intervention actions at all levels. Moreover, the traditions of social and critical epidemiology encourage a challenging of linear concepts of health, disease and causation to consider macro-level phenomena affect the local context. Social determination especially posits health (or the lack of health, that is harm) as an object produced or determined by the power structures of a society [61, 122]. Structurally violent society denies human beings the basic necessities of life, including health, through its political and economic organization, institutions, and the imposition of oppressive social arrangements [125]. Because  24 both social determination phenomena and structural violence are deeply engrained within dominant worldviews, they are ubiquitous, pervading nearly every aspect of human society. Insidiously, their ubiquity renders them less visible to the uncritical observer, which in turn contributes to the erroneous perception that they are less actionable [61, 126]. The theory of social determination emphasizes the importance of a paradigm shift in addressing health inequity at the local, regional, national and global levels; the power structures that perpetuate violent social arrangements are replicated at every level [126]. Without the frame of SDH and understanding that health is produced by a wide range of interconnected dynamics that must be addressed, sustainable solutions to complex health problems like dengue will continue to elude us. 2.2.1 The importance of SDH in dengue prevention and control Unlike the majority of the neglected diseases (ND), dengue fever and severe dengue (DF/SD) are considered primarily urban diseases [48, 60, 70]. Aedes aegypti biology and dengue virus (DENV) transmission dynamics in a densely-populated urban setting provide the foundation for epidemic spread of DF/SD spilling into sub-urban and rural communities as well. The key to DENV transmission is having a dense susceptible human population in the same endemic geographic area as a dense vector population with spaces for these two populations to interact. Urban environments lacking in public services, sanitation (addressing greywater, sewage and solid waste or refuse removal), piped water and/or reliable domestic water supply, with poor housing, lower socio-economic status and poor access to primary health care and health education provide ample social and environmental spaces within which susceptible human populations are exposed to infected vector populations [46, 48, 70, 127, 128]. Humans and their spatial and social associations influence DENV transmission patterns [30].   Dengue and its associated mortality are essentially a problem of domestic sanitation, water security, quality of housing and access to primary health care; all ?local? issues that are exacerbated by the macro-level phenomena of  25 globalization and urbanization [72, 78, 129]. Human health is a product of the social, political, economic and environmental forces that act on a given person, family, community or population [49, 59, 102]. Globalization, a process by which national and regional economies are linked through the production and consumption of goods and services, is changing the social, political and economic structures and processes that affect human health in the developing world [91, 130-132]. It is an exploitative force that further marginalizes the most impoverished nations and people, funnels resources away from them and carries deleterious health effects [91, 133].   Globalization of economies and production-consumption dynamics has influenced human migration and settlement patterns through the concentration of economic opportunities in urban centres. Urbanization is the rural-to urban migration trend whereby rural populations are forced to seek employment in urban centres because of rapidly increasing economic insecurity in rural areas [127, 134, 135]. These pressures combined with the global overpopulation crisis have resulted in a shift from 36% (1.33 billion people) of the world?s population living in urban centres in 1970, to 44% (2.42 billion) in 1994 and a predicted 61% (4.6 billion) in the year 2025 [127, 130, 135]. Much of this exponential population growth and urbanization is taking place in developing countries putting incredible strain on health systems, public infrastructure and the environment [136, 137]. Rapid uncontrolled or unplanned urbanization produces impoverished, overcrowded urban neighbourhoods and populations with inadequate, little to no sanitation, little to no access to a secure supply of safe water or to primary health care and that are politically and socially marginalized [59, 130, 137].  The effects of globalization and urbanization shed light on an important distinction that should be made when addressing neglected diseases (ND). The term ND is used to refer to a disease that has been neglected by funding, research, health innovation and development of pharmaceutical intervention. This may be the case, however, a far more important aspect of NDs is that they  26 primarily infect neglected populations totaling billions of neglected people [48, 49, 130, 138]. The biomedical and positivist research paradigms have fostered linear thinking regarding disease causation, that a person is ill or infected because of the presence of a pathogen or physiological dysfunction within their body. It does not address the underlying determinants, social dynamics or structural processes that perpetuate the illness or infection within the community the ill or infected person belongs to [46, 59]. NDs should be considered neglected diseases of neglected populations [139]. Looking at human health as the product of all of these factors may provide solutions to the DF/SD problem that vertical insecticide-based programs cannot.   As with disease and health inequity, there are macro-level determinants affecting the political will, resources and pressures to address and pursue solutions to these problems. The 17 diseases classified as ?neglected? are old diseases that the same populations have struggled with for centuries. The designation of ?neglected? is relatively new and is a part of a movement building momentum toward addressing these long-standing problems with research, development, innovative interventions and new delivery strategies [140]. This new push toward addressing NDs and their determinants is the synergy of key movements in funding, awareness and political will at the international level over a span of many years. In 1976 the Special Programme for Research and Training in Tropical Diseases (TDR) was created by the WHO, UNICEF, World Bank and UNDP to specifically address diseases of poverty [48]. This was closely followed by the Alma Ata declaration of 1978 in which the WHO declared that health is a human right and not just defined by the absence of disease. Rather, it posed health as a physical, mental and social state of well-being that requires participation from the people, multiple economic and social sectors in concert with the health sector. The Alma-Ata declaration saw a strong, intersectoral primary health care system as the main means to improving human health with a long-range goal of improving world peace through better human security [47]. This set the stage for a more significant focus on global health, addressing the  27 needs of marginalized populations (women, children, poor) and a movement toward an integrated approach to human health intervention and health care delivery.  Dengue is a persistent public health crisis in Ecuador, a country that began a political shift toward a more holistic approach to human health, governance and intersectoral collaboration with the creation of its new constitution in 2008. Sustainable solutions with the long-term vision and wide scope required to address the complex issue of dengue will be frustrated without examining the full spectrum of social and cultural determinants of health that it comprises. Local, equitable, participatory, short-term successes in dengue prevention and control will wither through the scaling-up and institutionalization process without specific consideration for the political and social driving forces of the disease. 2.3 The EcoHealth approach and the Eco-Bio-Social paradigm Intricate relationships linking human health, macro-level forces and non-medical determinants require research approaches that facilitate the wide consideration of global threats to human health through local-level action-oriented inquiry. EcoHealth and Eco-Bio-Social approaches attempt to address these challenges, with encouraging results in recent years [1, 62, 64].   An ecosystem approach to human health, or EcoHealth, has gained momentum within the vector-borne disease research and control community [109, 111, 119, 141-144]. Stated eloquently by Dr. Mariano Bonet, ?The EcoHealth approach recognizes that there are inextricable links between humans and their biophysical, social and economic environments that are reflected in an individual?s health [58].?  EcoHealth is based on the idea that improved human health will result from better understanding of the determinants of health and the societal response to those determinants [102, 139, 143]. In other words it sets up a feedback loop of research and action with the question of ?What produces good or poor health?? on one side and the responses of society (i.e. environmental modification, policy, changed behaviour) to the answers of that question  28 generated through research (Figure 3). In essence EcoHealth is a challenge to researchers to identify opportunities to improve human health and then test and refine strategies that address those opportunities [102, 139, 143].     Figure 3 - Iterative research/action loop proposed by EcoHealth incorporating determinants of ecosystem and human health and societal responses to opportunities to improve human and ecosystem health (adapted from Forget 2001) [143].  The definition of the ecosystem as used by EcoHealth, posits the ecosystem as an analytic concept with many layers of interdependent elements, each having influence over the other through their interconnectivity [102]. EcoHealth is integrative in that it considers management of the physical environment, economic factors and community aspirations or socio-cultural factors to be of equal importance; that human health is a product of the equal interaction of all of these factors [102, 143, 145]. These elements comprise EcoHealth?s analytic concept of the ecosystem, with the physical environment further subdivided into home, neighbourhood, urban, regional, national and biosphere environments (Figure 4) [102, 146].  Management of Natural and Human Resources Policy Development Societal Response to Human Health and Development Needs The Determinants of Ecosystem and Human Health Socio-cultural and Behavioural Factors Global-level Change Economic and Environmental Factors Knowledge Empowerment Improved Health  29  Figure 4 - The EcoHealth analytic concept of the ecosystem presenting human health as a product of the physical environment, socio-cultural factors and economic factors linked throughout the ?nested? layers of the surrounding environment (adapted from Forget 2001) [145]   The theme of sustainability is built into the EcoHealth model through the inclusion of human beings in the ecological paradigm and striving to promote sustainable development of human communities: ?development that meets the needs of the present without compromising the ability of future generations to meet their own needs? [102, 143]. Environmental and long-term intervention sustainability resonates well with the dengue-control research community, as there is a push toward community-based solutions and away from vertical insecticide-based programs. Similarly relevant is the tenet that stakeholders within the EcoHealth community of practice should include three groups: researchers and specialists, community members and decision makers; all working supported by three methodological pillars: transdisciplinarity, participation and equity [87, 147]. All of these are important to the effectiveness and sustainability of dengue control and prevention programs [102, 143, 148].  The EcoHealth approach to dengue control has been successful at the local level and shares common methodologies and a theoretical basis with the Eco-bio-Human Health  30 social approach [56, 102, 109, 111, 143, 144, 149-151]. Although the Eco-bio-social approach does not specifically hold equity (gender equity in particular) and participation as ?methodological pillars?, the two approaches are often linked in practice and are sometimes used synonymously [122]. These control efforts must incorporate an ecological element (i.e. environmental impact of control efforts, ecologically sound control measures, an ecological approach to human health), a biological element (i.e. mosquito control, use of entomological surveys and indices, human health and clinical data), and a social element (i.e. knowledge, attitudes and practices of at-risk human populations, communication strategies and perceptions of stakeholder groups, social effects of control programs on human populations) [119, 144, 152]. 2.4 Introduction to knowledge translation Research approaches to address complex health issues require interdisciplinary and intersectoral collaboration, stakeholders with experiences and knowledge that speak to the diverse fields of social, environmental and political determinants of health. Action-oriented approaches also require that these diverse stakeholders can collaborate in practice as well as theory; this requires strategies to share, mobilize, apply and evaluate the use of knowledge. I propose knowledge translation as a broad mechanism to support this collaborative praxis and to provide a foundation to address my overarching research question: How do current knowledge management strategies limit equitable participation and where are there opportunities to change? 2.4.1 History & theoretical roots of knowledge translation Knowledge Translation (KT) as a construct is relatively new to the health disciplines, and is gaining in popularity albeit surrounded by much nebulous rhetoric. It reflects growing attention manifest across various disciplinary and institutional settings in recent decades for improving connections between research and practice, that has been associated with a variety of terminologies [144]. The Canadian Institutes of Health Research (CIHR) conceived the term Knowledge Translation in 2000 as an innovative and widely encompassing  31 concept referring to the processes of generating and implementing knowledge in health practice as it relates to clinical practice, public health and health policy & programming [34, 36, 151, 153].  The definition of KT has evolved over the 10 years since its inception; definitions vary according to the disciplines and institutions in which they were conceived. CIHR originally defined KT as ?the exchange, synthesis and ethically-sound application of knowledge - within a complex system of interactions among researchers and users - to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health system? [34-36, 154]. CIHR has since adapted their definition to describe KT as ?a dynamic and iterative process? emphasizing its multidirectional character [37, 154].  The KT concept in this specific iteration originated with CIHR, so it follows that much of the literature surrounding it is steeped in language of health disciplines and is tailored to clinical practice. There are, however, other institutions and disciplines that are adopting the concept of KT and modifying definitions to suit. The World Health Organization defines KT as an emerging paradigm to learn and act towards closing the know-do gap by employing strategies that can harness the power of scientific evidence and leadership to inform and transform policy and practice [37, 154, 155].  Although the WHO definition of KT is still centered around health it more clearly emphasizes the ?action? element of KT through the implementation of knowledge to change policy and practice in multiple contexts [154]. The National Center for the Dissemination of Disability Research (NCDDR) defines KT as ?the collaborative and systematic review, assessment, identification, aggregation, and practical application of high-quality disability and rehabilitation research by key stakeholders for the purpose of improving the lives of individuals with disabilities? [156]. The NCDDR definition expands the original further to include not just improving health and health systems, but to improving quality of life of individuals through use of available evidence.   32 The increasingly popular KT paradigm does not have a well-defined, generally accepted comprehensive conceptual or theoretical framework. Rather, KT practices commonly feature similar goals, assumptions and tools in their operation and thus contribute to the growing body of evidence and experience around KT and the ongoing development of best practices for KT [36, 154, 156].    The belief that policy and practice should be based on the best and most sound evidence available is the core principle of KT. This makes it inherently an action-oriented approach wherein the generation of knowledge is not an end, but is an intermediate step in an iterative process to refine and improve practices that address real-world issues. The concepts of the ?know-do gap? and ?evidence-based practice? are often invoked in discourse surrounding KT. The ?know-do gap? refers to the discrepancy between the practice prescribed by sound, available evidence and the practice that is employed on a day-to-day basis [35, 154, 157-159]. Evidence-based practice refers to tailoring interventions, strategies and service delivery to reflect the most suitable way to address issues, concerns or problems as shown by research evidence [154-156, 158, 159]. The invocation of evidence-based practice in KT discourse points to the important assumption that the ?knowledge? referred to in KT is research-derived [37, 156]. This presents a fundamental bias toward the valuing of academic, institutional, peer-reviewed or formal knowledge over types of knowledge held outside the realms of research and formal evidence-generating pathways (i.e. lay, traditional, aboriginal and/or community knowledge) [154].   As defined by CIHR, KT involves the active exchange of knowledge between researchers who create new knowledge and the people who use it [37, 159].  Multiple research users within a complex system of health care and service delivery dictate that KT be a non-linear and interdisciplinary process heavily relying on multi-directional communication strategies.  It also implies that KT must be contextual; that the process of KT should facilitate the uptake and application of knowledge by a given user through its presentation in a  33 contextually appropriate and user-specific manner [33, 158]. For example, new knowledge around domestic violence prevention strategies would be relevant to public health nurses and the community in different ways and should be made accessible and understandable to these different groups accordingly. Each issue brings with it a diversity of stakeholders and stakeholder groups including but not limited to administrators, researchers, communities, individual recipients of care/knowledge, organizers, lay and trained practitioners, governments and government officials at all levels, private sector actors, advocates and advocacy groups, institutions, media, the general public and the public sector. It is important to note that research producers are also research users in this iterative process.   KT emphasizes uptake and application of knowledge by users with the ultimate goal of positive health impact, thus it includes each step of the process from new knowledge generation to knowledge application and impact assessment [33, 37, 154, 160]. Graham et al. (2006) present a 7-step KT model in which knowledge is created, adapted and transmitted for uptake or use in the context of a specific health problem, then followed by a knowledge use impact assessment leading to a new KT cycle [154]. CIHR presents a KT model based on a research cycle in which there are 6 opportunities for facilitating KT [33, 34, 37]. The model identifies these as junctures in the KT process at which collaboration, interaction and communication between knowledge producers and users will promote KT and the generation, uptake and application of knowledge (Table 1).  CIHR?s KT model attempts to graphically illustrate a process that includes knowledge dissemination, communication, technology transfer, ethical context, knowledge management, knowledge utilization, two-way exchange between researchers and those who apply knowledge, implementation research, technology assessment, synthesis of results with the global context, and development of consensus guidelines [154].   34 Table 1 ? Comparison of knowledge translation models presented by Graham et al. (2006) and CIHR (2007) KT Model, Graham et al. (2006) KT Model, CIHR (2007)   Step Definition Step KT Opportunity Knowledge creation Process through which major types of knowledge are refined by research to be made more valid useful to healthcare systems. * Research Cycle Process Engage research knowledge users Identify problem and review knowledge Identification of a problem by a group or individual and searching for knowledge or research to address it KT1 Defining research questions and methodologies Adapt knowledge to the local context Decision-making process through which the value, usefulness and appropriateness of particular knowledge to the specific issue, setting and circumstances * Research Cycle Process Contextualizing knowledge within the global knowledge on the issue  Assess barriers to knowledge use Implementers asses for potential barriers that my impede knowledge uptake as well as uptake facilitators KT2 Conducting research (as in the case of participatory research) Select, tailor and implement interventions Planning and executing interventions to facilitate and promote awareness and implementation of the knowledge KT3 (with a direct path leading back to research user engagement) Publishing research findings in plain language and accessible formats Monitor knowledge use Defining and measuring knowledge use KT4 Placing research findings in the context of other knowledge and sociocultural norms Evaluate outcomes Evaluate the impact of knowledge use or application KT5 Making decisions and taking action informed by research findings Sustain knowledge use Determining the sustainability of the knowledge use KT6 (leading back to engagement of research users) Influencing subsequent rounds of research   Knowledge translation, in the Canadian context and beyond, is understood to incorporate both end-of-cycle KT and integrated KT; each of which plays a specific role and carries corresponding implications for the research process and equitable participation [37]. End-of-cycle KT (also referred to as end-of-grant) encompasses the activities researchers plan and carry out to make stakeholders aware of innovative and potentially useful knowledge resulting from a research cycle or project [154]. Integrated KT takes place longitudinally over the life of the research process, with stakeholders and other knowledge users involved at each step [161]. While integrated KT by definition incorporates the notion of equitable participation and dynamic knowledge exchange during planning, design,  35 implementation, analysis and reporting, impact and stakeholder ?buy-in? does not necessarily follow [34, 161]. The fields of knowledge-to-action and KT are burgeoning in the health sector and beyond; of particular note are the innovation and attention to context-specific models, social mobilization and health equity [162-164]. Although there are several identified KT models that support public health action to improve health equity, there is still a need to continue to develop and refine KT theory and practice to include a focus on health equity in a more robust way [33]. Models that explicitly incorporate considerations for promoting and improving health equity and social mobilization, recognizing the crucial role of contextual factors in problem solving approaches, and drawing on knowledge from multiple sources are most promising [165].   2.4.2 Knowledge valuation schemes: historical & present Since the term Knowledge Translation was coined in 2000, it has influenced how health research is done in Canada and internationally [37, 154, 166]. The CIHR KT model is neither a completely novel idea, nor can it be divorced from the social context within which it was created [154-157, 167]. Although these KT models offer new developments and strategies in the research cycle, they still operate within systems that perpetuate conventional value judgments on types of knowledge and equitable knowledge creation. Theoretical and practical precursors to the KT concept have shaped its rhetoric and the way it uses different types of knowledge. There are significant challenges to the notion that KT as defined by CIHR and Graham et al. (2006) can be used as a stand-alone emancipatory action research method to improve human health and quality of life. Without the additional framing through the lenses of SDH, health equity and the inclusive concepts of health embodied in EcoHealth and EBS approaches, KT may not reach beyond its roots in diffusion of innovation and biomedically-oriented evidence-based practice.  Rogers? Diffusion of Innovation Theory (DIT) conceived in the 1960s has had substantial influence on the development of the KT concept through its pervasive use in knowledge management and transfer theory and practice[35, 37, 156,  36 168-170].  Diffusion of Innovation Theory describes and explains the manner in which an innovation or new idea spreads throughout social systems [154, 171].  Specifically DIT looks at how innovative products spread through markets and are adopted by individuals and groups. The theory originated in the realm of technology and marketing and describes four elements that determine the spread of a new idea: 1) the innovation itself, 2) communication channels, 3) time, and 4) a social system [168-170]. In addition there are five characteristics of an innovation that will influence the rate at which the innovative product will diffuse: i) The advantage that the innovation brings to those who adopt it, ii) the compatibility of the new product with the adopter?s experiences and values, iii) the complexity of the innovation and/or how readily the adopters can implement or apply it, iv) the divisibility of the innovation (whether an innovation can be used piecemeal or must be adopted in its entirety), and v) how readily beneficial results can be observed and directly attributed to the adoption of the innovation [170, 172].   Applying this theory to knowledge and the uptake and utilization of knowledge within a group of stakeholders has been instrumental in the development of contemporary KT models. Replacing the new product or innovation with ?new knowledge? and superimpose DIT on health service delivery and research systems reveals that the translation of new knowledge into evidence-based practice does not depend solely on the scientific merit or rigor of the knowledge but on how that knowledge is perceived by influential groups within the system over time [168, 170].  Hearkening back to the idea of a social system is important here in that the general public and society itself should be included in the health service delivery and research system.  An important aspect of this theory is that it arose from the fields of rural sociology and agricultural economics and was originally written referring to commodity exchange not to a learning organization or health systems [169, 170]. The evolution of modern KT practice from commodity theory leads to a culture that  37 views new knowledge as a commodity to be traded between producers and users rather than a shared resource [170]. Knowledge as a commodity evokes economic language and theory in knowledge management literature; within that atmosphere knowledge is categorized and value judgments are placed on different knowledge types [159, 172]. Health systems, and by proxy KT literature as it originated in the health field, value research-derived knowledge (often called evidence) over all other types of knowledge[159, 173, 174]. This results in a constricted scope for change and innovation in a field where many different types of knowledge contribute to and sustain human health and quality of life. Evidence is often created in an artificially sterile (experimental design and control) environment that generally overlooks the influence of other forms of knowledge in decision-making processes. Experiential knowledge, personal knowledge and collective/cultural knowledge are not considered as legitimate on the same level as evidence and rarely form the rationale for decision-making[37, 154].   The CIHR KT model, however, deliberately addresses this hierarchical valuation of evidence and knowledge by explicitly stating that new knowledge should be integrated with existing and other forms of knowledge and sociocultural norms and to emphasize that the context of the issue being studied is integral to successful innovation [169, 173, 175]. The context of an issue under scrutiny is often deconstructed into sociocultural norms, local or community knowledge, beliefs, behaviours and practice; the experiential knowledge of the issue as it is dealt with on a day-to-day basis. While it is true that understanding context and the adaptation of evidence to the context of an issue is essential to its translation into action (revisiting the idea that it is the social system that diffuses innovation based on perceptions of the innovation ?transmitted? from one individual or group to the next [37, 154, 168], this promotes the idea that context is more valuable as an evidence transmission vehicle than as an important source of knowledge in and of itself.    38 The health sciences are firmly rooted in the positivist paradigm and have been for hundreds of years. The valuation of research-derived knowledge above other forms of knowledge naturally evolved from these roots as shown by a strong emphasis on evidence-based practice within the health disciplines[169, 170].  At its core, practice consists of decisions made and a course of action pursued based on those decisions. Evidence-based practice (EBP) seeks to have research-derived knowledge or evidence determine how decisions are made rather than tacit, experiential or personal knowledge [169, 173]. The hierarchical valuation of knowledge in EBP decision-making extends further by categorizing types of evidence and assigning levels of ?trustworthiness? to each category. There is a general trend in the hierarchy toward increased scientific rigor correlating to increased trustworthiness of the evidence; the systematic review of randomized controlled trials being at the top of the hierarchy (Table 2)[176, 177]. The reliance on increasingly esoteric forms of scientific evidence serves to remove programming, practice and decision-making from the interface between practitioner and the public to the realm of administration and policy-makers[177, 178]. Table 2 ? Hierarchical organization of types of evidence that inform decision-making processes in Evidence-based practice from most to least trustworthy[173, 179] Relative strength of evidence Type of scientific evidence I Strong evidence from at least one systematic review of multiple well-designed randomized controlled trials (RCTs) II Strong evidence from at least one properly designed RCT of appropriate size III Evidence from well-designed trials without randomization, single group pre-post, cohort, time series or matched case-controlled studies IV Evidence from well-designed non-experimental studies from more than one centre or research group V Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees   There have been incredible advancements in the delivery of health services and in public health because of reliance on EBP and sound scientific research[177]. There is international call for the increase of the use of evidence in creating policy, programming and informing clinical practice; it is often coupled with the  39 notion that a strong health care system cannot exist in the absence of a strong health research system firmly linked to it[52, 99, 178, 180]. At the systems level, EBP can increase accountability in service delivery, reduce variation in care and programming, and improve health outcomes. EBP embodied in clinical guidelines and public health policy and can streamline practice, programming and service delivery, and manage risk effectively by blending the most reliable evidence available with patient preferences (clinical) and/or local context and knowledge (public health)[100, 180]. Evidence based practice and evidence based public health also incorporate reflective practice to evaluate how the decisions made performed in solving problems or positively impacting health issues[155, 160, 180].   The 5 basic steps of EBP are to 1) convert information needs into answerable questions, 2) gather the most reliable evidence available to answer questions, 3) critically appraise the evidence for validity and utility, 4) apply evidence in clinical practice (or public health programming) and 5) evaluate the performance of the decisions made or interventions undertaken [169, 181].  This process has striking similarities to the CIHR KT model in that answerable (research) questions must be designed in the context of a clinical or real-world problem, evidence must be gathered (or created) to address the issues, it must be implemented and then evaluated for impact (Table 3). Continuing medical education and continued professional development are important aspects of EBP, but they are primarily teacher- and learner-driven and don?t readily allow for integrated or multi-disciplinary solutions to contemporary issues in the health disciplines [180]. The focus on action and the implementation of formal knowledge in practice combined with the social communication and subjective experiential evaluation of innovation in Diffusion of Innovation Theory begins to resemble a theoretical base for the contemporary construct of KT.   40 Table 3 ? Commonalities in evidence based practice and the CIHR knowledge translation model  Element in evidence based practice Element in knowledge translation 1) convert information needs into answerable questions KT1: Defining research questions and methodologies 2) gather the most reliable evidence available to answer questions KT2: Conducting research (as in the case of participatory research) 3) critically appraise the evidence for validity and utility KT3: Publishing research findings in plain language and accessible formats KT4: Placing research findings in the context of other knowledge and sociocultural norms 4) apply evidence in clinical practice (or public health programming) KT5: Making decisions and taking action informed by research findings 5) evaluate the performance of the decisions made or interventions undertaken KT6: Influencing subsequent rounds of research    There is, however, an emerging body of work (particularly in the nursing literature) that calls for a redefinition of ?evidence? to one that includes more diverse body of knowledge upon which to base decisions in the health disciplines [181]. It is widely accepted in the literature of both EBP and KT that evidence is not the only basis upon which decisions are made; that personal experience, context, lay knowledge, clinical expertise, intuition and the ?apprentice? factor (i.e. taking on decision-making characteristics of a mentor without the formal adoption of a decision-making rubric) all influence decision-making processes [36, 155, 173, 179-182]. These informal sources of knowledge and practice, however, continue to be undervalued which may be contributing to an power imbalance in decision-making at all stages of the knowledge translation and/or evidence based practice cycle. In this knowledge valuation dynamic, power is often concentrated with the groups who produce the ?valuable? knowledge (i.e. scientific evidence) to the exclusion of those who do not have access to formalized knowledge creation pathways.  In this sense, knowledge valuation is inextricably linked to the political, social and cultural context within which it is produced, used and evaluated. Although KT strives toward equitable participatory approaches, it is effectively limited by the qualities and structures of the systems, institutions and individuals that  41 endeavour to undertake it. In the case of public health and dengue, these systems and institutions tend to be hierarchical organizations that rely on expert, technical and quantitative evidence that is produced, valuated and used in ways that perpetuates existing institutional knowledge monopolies [173]. At the heart of its theory and practice, KT makes an assumption that the involvement of a research-centric knowledge mediation process is both validating and democratic. The notion that health and university-based research systems are divorced from these knowledge monopolies is short sighted. Although the research-centric power structures may be more moderate or inclusive to various ways of knowing, they still represent a concentration of power in the decision-making and knowledge management process that serves to exclude agendas, issues, questions and results that do not coincide with institutionally established priorities.   At the macro-level, institutional priorities are often set by funding agencies, governments and industry partners, all of whom are embedded in the conventional, hierarchical economic, political and social structures. The innovation of KT continues to be important for policy change and public health programming improvement; much of the literature in participatory research using KT implies that the process is geared toward knowledge users, the group of people targeted with specific knowledge and who are expected to exhibit a measurable impact. The concept of knowledge users may be misleading, in that often the largest impact with the most sustainable outcome would be deep political shifts in ideology and structure, policies that would address the upstream determinants of health, and inclusive agenda-setting on the macro-level. Within existing knowledge valuation systems and power structures, policy-makers and funders should be considered as driving-force knowledge users that determine research, KT and participatory processes themselves.    2.4.3 Implications for KT in the scaling up process The term ?scaling-up? is often used to describe the process that seeks to bring the successful results of research projects (small or local-scale) to influence the  42 experience (i.e. improving quality of life, changing service delivery protocols, public health education campaigns) of a larger population (provincial, national, regional, global levels). Scaling-up of interventions requires the use of research-based knowledge by institutions and organizations (governmental and non-governmental) to change practices, perceptions and behaviours both within their own entities and to promote the same in others (institutions, organizations, government, general public).    The notion of evidence based policy gained in popularity in the 1990s during the promulgation of evidence based practice in the clinical setting [169]. Arguments for evidence based policy assume that scientific evidence or research-based knowledge is taken up by policy-making bodies and used by decision-makers to create a framework responsive to that evidence that will govern programming and practice in day-to-day operations [181, 183-185]. Evidence based policy models often assume that research-based knowledge is ?taken up? from the local level by policy-making bodies and that it trickles back down to the local level in multiple different locations and contexts with positive impacts in tow. Defined loosely, the local level can be taken to mean a single small town or community or can be expanded to a regional level such as WHO multi-country regions. The scaled-up level may be then defined as anything from a small cluster of towns or communities to areas including more than one WHO multi-country region or the global level. Policy-making entities also exist at multiple levels; from non-governmental community associations to Federal Governments to the United Nations and the like.   The relationship between evidence and policy, however, is not linear nor can it be assumed that evidence created in one local context will be effective in other local contexts without adaptation, tailoring or further investigation [33, 155, 180, 184, 186, 187]. Evidence based clinical practice centers around using research-based knowledge to make care decisions in the context of a particular patient?s experience and health. Expanding the context to include the experience, health,  43 goals and culture of communities and populations dictates that the decision-making and policy-making processes should also be expanded to capture contextual nuances in the complex network of actors involved [33, 180, 184, 187-189].   KT processes may provide opportunities for producers (or holders as the case may be with traditional, cultural or lay knowledge that is held within a body of people rather than produced by it) and users of knowledge and evidence can communicate effectively to achieve positive impact through a participatory decision-making process. Rather than relying on knowledge producers to impose their knowledge on users in a ?push? strategy, or on knowledge users to reach out to existing forms of knowledge and evidence to answer self-identified issues in a ?pull? strategy, KT advocates for exchange or cooperation between knowledge producers and users[188]. Ideally, this ?exchange? becomes integrated management and policy-making at the expanded population and policy levels and requires intersectoral cooperation and action to improve quality of life [189-191]. KT platforms seek to streamline this process but must be supported by efforts in participating institutions, organizations and stakeholder bodies to incorporate new knowledge and learning strategies in their day-to-day operations.  Policy windows also play an important role in knowledge translation and research-to-policy processes. Policy windows depend on political will, recognition and awareness of issues and the mobilization of policy development resources and infrastructure. These three conditions allow for the finalization and institutionalization of new or changed policies that determine programs, service delivery and impact on real-world problems [192].  Kingdon?s (1995) multiple stream model of the policy-making process conceives of a policy window as the product of three main streams converging: the politics stream, the policy stream and the problem stream [190]. Political will, or the politics stream, can be seen as a product of time, place and political mood; new leaders, changes in government  44 structures, public pressures and catastrophic events can contribute to the willingness of a governing agency to engage in the policy-making process. Policy streams refer to the options and alternatives proposed by experts, decision-makers and knowledge producers to address identified issues. The problem stream is the set of issues recognized by the policy makers as problems that ought to be addressed [124, 193]. Policy entrepreneurs may play a significant role in moving the problem and policy streams into alignment with the politics stream through continued and repetitive communication and or relationships with policy-makers, can cultivate political will and/or a political ?micro-climate? amenable to a particular issue and the knowledge associated with it [124, 181, 194].  This policy-making model highlights the importance of intersectoral collaboration and KT in the scale-up process of successful local participatory EcoHealth-style interventions. Without the involvement of decision-makers, advocates, knowledge producers and policy-makers together, the probability that the three streams would converge in a timely fashion to act on local, community-based evidence is very small. These actors, from all different stakeholder groups, bring the advantages of their social networks, social and political capital, expertise and capacity for action to the policy-making process. As these actors collaborate, networks merge and their qualities and attributes may be shared, transferred or stunted depending on the political streams that flow through the functional intersectoral spaces. Great care must be taken to acknowledge the necessity of equitable participation and knowledge valuations in these power-sensitive environments; even solid evidence generated through perfectly equitable, transformative and emancipatory collaboration could mutate to conform to existing structures particularly in high-powered and high-pressure policy windows.  2.5 Participatory indicator development Knowledge translation as part of the scaling-up and research-to-policy process depends on evidence, or knowledge that has been rigorously evaluated and that is believed to  45 hold potential for innovation and positive outcomes. Evaluation processes are the filters through which knowledge passes in order to engage the decision-making and policy processes. Indicators and evaluation strategies are selected at the ?issue-framing stage? and in line with research goals and objectives [186].  Conventionally, issues are framed through expert opinion and influenced by overarching research agendas set through funding agencies, governments and institutions. These actors determine which elements of interventions are measured and how successes and shortcomings are reported. Indicators, then, bear the same biases as the research agendas and power structures that establish them [195, 196]. Evaluation can be exclusionary to non-expert knowledge and to wider conceptions of the production of health or harm.  Participatory indicator development offers an opportunity to facilitate equitable participation and power sharing in the evaluation process. Indicators must satisfy requirements of rigour, however, they also must serve the wide requirements of a variety of stakeholders and the demands of understanding complex issues [197, 198]. Indicators dependent upon linear, scientific and technical information may not be capable of describing qualitative nuances of lived experiences and how they are affected by interventions. Moreover, the information that these indicators relay to decision-makers is not accessible to unspecialized collaborators. In addition to rigour, validity of indicators also depends on the process through which they are selected and employed [197, 198]. Participatory research and development should employ participatory means to develop indicators and evaluation strategies that reflect the richness of experience and ways of knowing of the broadest and most inclusive body of collaborators. Equitable participation in the development of indicators and evaluation strategies will require the renegotiation of cultural and social dynamics deeply connected to the production of health and harm. Specifically, the social determinants of dengue in Machala include political structures, agendas, decision-making routines and policies that must be challenged directly in order to meaningfully engage in participatory indicator development.      46 2.5.1 Social multi-criteria evaluation as a participatory process Health is deeply connected to place [121, 198]. Social, cultural and political forces are highly variable from place to place, thus, the interface between local and global processes takes on unique dimensions in time, space and place. Relying on evaluation strategies that have been transplanted without consideration for the unique local context limits the potential for local relevance of results, and may decrease sustainability of resulting programs and policy [199]. Social multi-criteria evaluation (SMCE) suggests that multi-dimensional strategies to address complex issues involving human systems must be evaluated with context-specific multi-dimensional tools. The reflexive relationship between human health and social, cultural and political systems in borne out as well in public health program evaluation and policy-making [200]. Multi-criterion decision-aids as part of an equitable, participatory and socially focused research-to-policy process provide a rigorous way to systematically include indicators representing conventionally marginalized voices alongside specialized, technical indicators. Importantly, SMCE requires that decision-makers engage in a process of contextualizing selected indicators. The nomenclature of ?decision-aids? implies that decisions must be considered products of a longer, more meaningful process of engagement with involved stakeholders, rather than as events dictated by arms-length measurements and esoteric mathematical models. As well, care should be taken that the legitimizing of decisions made through equitable participation must not be construed as an opportunity to shirk political responsibility for resulting programs [59]. Victim blaming may be reinforced through political manipulation of the results of ?failed? or ?unsuccessful? participatory programs; this unfortunate dynamic may be exacerbated if participatory indicator development or SMCE is used as scapegoat.      Social multi-criteria evaluation frameworks seek to make evidence of participatory research accessible to a wider variety of stakeholders, essentially opening the equity bottleneck. Designing SMCE decision-aids for local relevance and validity should consider: i) ease of use and inclusivity  ii) process and end-point evaluation   47 iii) appropriateness and utility of results iv) potential influence on determinants   Specific to the case of scaling-up participatory dengue prevention and control in Machala, the development and use of an SMCE decision-aid should consider:  i) use of tool in intersectoral spaces to promote knowledge sharing ii) process evaluation reflecting on collaboration, perceptions and communication between diverse stakeholder groups iii) end-point evaluation reflecting re-defined measures of short, medium and long-term success iv) innovation in knowledge valuation schemes and active engagement with social, cultural and political dynamics Ultimately, the participatory process of developing an SMCE decision-aid should be additive or multiplicative rather than antagonistic. Trusted indicators that rely on expert knowledge and priorities should not be discarded simply because they are unable to capture an adequately complete picture of the social production of dengue risk in Machala. Instead they should be seen as vital elements in a holistic description that demands the complement of qualitative, experiential and tacit knowledge in order to better convey the true and complex nature of dengue fever as a human health issue.  2.6 Theoretical foundations for methodological choices Dengue fever as an increasingly important public health issue at the global level demands innovative thinking from those who would endeavour to address the complex challenge it presents. Interdisciplinary and intersectoral collaboration are promising approaches, but they propose complex challenges in and of themselves. Knowledge translation and participatory indicator development offer the foundations for moving innovative collaboration and partnerships from theory to practice, and underscores the need to begin with a strong emphasis on understanding local contexts, equity and transformative emancipatory framing of participatory work. Thus, methodologies should be chosen in alignment with these theories and that seek to establish new and creative spaces to challenge outmodes strategies, oppressive power structures and unjust social dynamics.  48 The methodological choices I have made to these ends and their specific theoretical underpinnings are explored further in Chapter 3.   49 Chapter 3 ? Methods The methodological choices I have made in this study build directly on the historical and theoretical foundations established in Chapter 2, situating dengue as a multi-faceted issue, with a wide range of determining forces and factors. The first sections of this chapter (3.1 and 3.2) discuss the logic and merit in employing participatory and mixed methods to meet the challenges of addressing the overarching research question investigating knowledge management strategies and their impact on equity in participatory dengue prevention and control. As discussed in the previous chapter, these guiding methodologies provide a robust practical response to the identified weaknesses of the KT mechanism. Section 3.3 describes the physical setting of the study and the communities involved in this work. The latter sections of this chapter (3.4 ? 3.7) discuss the specific techniques used to address the specific research questions outlined in Chapter 1. An overview of methods used is provided in Table 4.   50 Table 4 ? Overview of methodologies and timeline Methodology n Data Dates field notes document analysis Ethnographic observation n/a event notes June 2010 - May 2013 Community meetings 60 field notes January 2011 - May 2013 Intersectoral stakeholder meeting 170 field notes February 27, 2012 July - August 2011 audio February - March 2012 September 2011 - January 2012 Focus Groups  14? transcription April 2012 - June 2012 July - August 2011 audio February - March 2012 September 2011 - January 2012 Interviews 27 transcription April 2012 - June 2012 Coding  -   -  September 2011 - September 2012 Social network analysis  -   -  September 2011 - September 2012 Participatory indicator development 120 themes/codes  -  Survey 119 likert data March 18 - April 6, 2012 Meetings  60? notes March 25 - 31, 2012 phone survey Follow-up 60 comments April 2 - 6, 2012 Principal component analysis  -  survey data *January 2013 Hierarchical clustering analysis  -  survey data *January 2013 Community participation, empowerment & wel-being survey 1888 likert data *March 2012 ? 14 focus groups with 61 total participants; ? Meetings were primarily held for the 60 community participants  3.1 Mixed methods for applied health research Participatory EcoHealth or Eco-Bio-Social style dengue control presents a challenge to researchers, communities, public health officials and practitioners in that they require both qualitative and quantitative methods. Dengue transmission, and therefore dengue prevention and control, lies at the interface between human and mosquito populations; different techniques, metrics and analyses are required to monitor and understand the effects of dengue and dengue control on each of these populations. Interactions of humans with their environment are complex and understanding nuances may be key in developing effective and sustainable control strategies within specific communities and environmental contexts.     51 The human experience is difficult to quantify; emotions, attitudes, motivations, culture and relationships all have qualities that cannot be measured or conveyed with quantitative data in the traditional positivist paradigm. Qualitative methods allow research to access the heart of human experience; perceptions, opinions, feelings, attitudes, interpretation of events (hermeneutics) and the nature, function and value of knowledge (epistemology) in everyday life [200-204].  When working with a community on behavioural or social change (i.e. managing environmental risks to human health through dengue control), it is important to know the meaning that community attaches to the issue at hand (dengue) and the social change required to address it (community-based dengue control). Qualitative methods provide access to personal and social meanings, individual and cultural practices and how these exist within the physical environment and social context of a community [205, 206].  With respect to community-based dengue control (which focuses on community participation in the reduction of mosquito breeding sites, education campaigns and cooperation between individuals and groups of individuals), the complex relationships between social norms, culture, perception of risk, perceptions of other people or groups of people, and the importance of dengue as an issue within an individual?s and the collective consciousness of the community can all affect a program?s success. Qualitative methods are required to understand the human side of the human-mosquito interface of community-based dengue control.  The other side of this interface is the ambient mosquito population. This can be seen as solely what kinds of mosquitoes are in the physical environment, how many there are and how many are carrying dengue virus. To be useful to control efforts of any kind, this view should be expanded to include the conditions of the natural environment that affect mosquito populations; temperature, rainfall, humidity, mosquito population density, human population density, density and quality of breeding sites/habitats, larval and pupal densities within these sites/habitats, presence and density of predators in these sites/habitats, distance between individual or clusters of breeding sites/habitats, tree or brush cover in  52 the environment, wind direction, wind speed and day length [204, 206].  Quantitative date describing these characteristics of the vector (mosquito) population, host (human) population and the physical environment are instrumental to understanding dengue transmission dynamics, evaluating disease risk, predicting outbreaks and evaluating dengue prevention and control programs [27, 207].   The nexus of environment, humans and mosquitoes in dengue transmission requires researchers to expand methodologies to gather data descriptive of the complex nature of this interaction; both qualitative and quantitative methods are required to achieve this. The positivist paradigm of quantitative methods reliant on empirical evidence complements the interpretive or subjective nature of qualitative methods to achieve a holistic description of dengue transmission and community-based strategies for its prevention and control.   Mixed method and multiple method research use a set of complementary methodologies from both the qualitative and quantitative schools, and blend philosophical assumptions and methods of inquiry to investigate complex research questions that single approach designs cannot answer [208-211].  A mixed method design specifically calls for the use of qualitative and quantitative strategies of inquiry and investigative methods, while a multiple method design implies the use of more than one method within a single (either qualitative or quantitative) strategy of inquiry [204, 206]. When researching as complex an issue as community-based dengue prevention and control, it can be expected that multiple methods will be used on both the qualitative and quantitative sides of a mixed method design; accurately capturing a complicated picture requires different lenses positioned at different angles.  Mixed method design has gained recognition as a third, emerging research paradigm, but not without controversy or contention. Although the mixed method design combines the strengths of two different paradigms to answer ?otherwise  53 unanswerable? questions, there is debate in the literature as to whether the data or knowledge from these disparate paradigms (i.e. positivist/empiricist vs. interpretivist/constructivist) can be combined without compromising its integrity or validity [206, 211-214].  Following the logic that different methods and paradigms can answer different types of questions, it also may follow that the data may be discordant and will not produce a final ?holistic? picture but a chaotic body of incoherent or contradictory knowledge.  Just above this incompatibility argument, there is a belief that mixed methods can work if paradigms and their respective results are kept separate so that their will complement one another; methods either executed in tandem or sequentially [204, 206, 211].  Conversely, there is support for the blending of paradigms to form a dynamic single paradigmatic platform, thus avoiding the issue of discordant worldviews and complete abandonment of paradigm itself.  The transformative-emancipatory paradigm (TEP) is a blending of the positivist (quantitative) and interpretive-constructivist (qualitative) paradigms [206, 210, 211]. It considers knowledge as essentially linked to the values, interests and status of the people who generate, use and interpret it; bringing together qualitative aspects of the human experience (values, opinions, culture) and empirical knowledge (mosquito density, disease risk metrics). Social Justice forms the foundation of TEP; it links knowledge and research to action in a way that seeks to change asymmetric power dynamics, social inequity and the marginalization of people or groups of people [215]. A central methodological assumption of TEP is that all communities affected by the research will be involved in the research and will have influence in methodological and programmatic decisions, with special consideration given to populations that are traditionally underrepresented [211]. EcoHealth and CBAR echo the assumptions and theoretical foundations of TEP (Table 5), naturally fitting into a cohesive approach to community-based dengue prevention and control action research: CBAR using mixed methods informed by EcoHealth and governed by TEP.    54 Table 5 ? Principles of the Transformative-Emancipatory Perspective (TEP), the ecosystems approach to human health (EcoHealth) and community-based action research (CBAR) form consensus on guiding research methods Methodological approach TEP EcoHealth CBAR Transformative Participatory Democratic/Inclusive Emancipatory Gender Equity Equitable Equitable Transdisciplinary Enhancing Social Justice Ecosystem-based Liberating  The terms ?community-based? and ?participatory? are often used interchangeably; however, there is an important distinction to be made. The popularization of participatory approaches in recent decades has led to the appropriation of this language and rhetoric by the power structures that they once struggled against. Originating with an emancipatory practice of oppressed peoples, these terms, techniques and ideals have been changed to accommodate the institutional and political agendas of funding agencies, governments, universities and researchers to achieve measurable impact [66, 215]. This appropriation has led to a muddying of the definitions and implications of community-based research. At its inception, community-based research involved the community at every step of the research and development process, including determination and definition of research issues, questions objectives, methodologies and deliverables. Research agendas were deeply seated within the community experience and the purpose of the research was to improve day-to-day quality of life by addressing issues in a manner consistent with the needs and context of community life. More recently, the terms ?community-based? and ?participatory? may describe research that includes a population-based intervention, community consultation, interactive messaging or a strategy that requires volunteer participation to carry out project objectives; none of which imply or depend upon equitable community participation or emancipatory praxis. The newer terms ?community-placed? and ?community-driven? have emerged in the discourse to distinguish the varying shades of participatory research. Community-placed research implies that the community is not is no meaningfully involved in the determination of the research  55 agenda, issues, questions, methodology or evaluation, but may be involved in the execution of the work. Community-driven research implies the original intent behind CBAR, to work in equitable partnership with communities in addressing self-identified issues in culturally and socially appropriate ways.  3.2 Importance of participatory methodology  Participatory methodology in public health and global health research has experienced a resurgence in popularity, particularly with smaller-scale projects addressing complex health issues like dengue fever [183, 216]. Participatory research methodology aimed at non-medical determinants of disease transmission is a strong theoretical axis for dengue prevention and control research in Latin America and the Caribbean, as well as other regions around the world [58, 142, 217]. The majority of the literature features local successful prevention and control efforts that either lack the funding and/or time allowance for scale-up, or that lose effect upon extension to larger geopolitical scales [77, 109, 111, 139, 144, 150, 151, 218].   The Eco-Bio-Social paradigm (EBS) employed by the World Health Organization (WHO) through their Special Programme for Research and Training in Tropical Disease (TDR) and the EcoHealth paradigm conceived of and popularized by Canadian researchers both emphasize the importance of equitable community participation in the identification of health issues, conception of research questions and projects, evaluation of the projects and implementation of recommended strategies in order to achieve a sustainable, effective and acceptable health intervention [102, 122, 152]. Often in the case of EBS and EcoHealth-style dengue prevention projects, sustainability is treated as an achievable objective or an output value that can be measured and maximized through the participatory process [14, 143, 148]. As well, acceptability and efficacy are tightly linked and narrowly defined in quantitative epidemiological terms; the reductions of both epidemiological and entomological indices are seen as irrevocably tied to the personal values and behaviours of program participants. Participatory strategies like Communication for Behavioural Impact  56 (COMBI), social mobilization, EcoHealth Approaches, and EBS all firmly assert that addressing the links between environmental, social, political, cultural and biological factors and human health also require a knowledge translation (KT) process that facilitates behaviour change and changes in policy, programming and practice to improve human health [30, 56, 102, 119, 149]. This KT strategy ought to include a participatory evaluation process that leads to policy recommendations and that serves to i) launch a new iterative participatory action research cycle and ii) strengthen intersectoral collaboration and forge new intersectoral spaces.   The methodological choices made in this body of work were deliberately done to, insofar as possible, elevate equitable participation to an objective in and of itself, rather than a means to achieving a higher objective. The gross evaluation framework of the EBS parent project (EBS-Ecuador project), ?Meeting capacity-building and scaling up challenges to sustainably prevent and control dengue in Machala, Ecuador?, that provides the foundation for this work was determined by expert opinion and based on the results of pilot studies without the participation of the multi-stakeholder group. Nevertheless, a concerted effort to open the research and evaluation process to as many stakeholders as possible, in the most transparent way possible has been made in the design of overall methodology, instruments, communication tools, analyses and knowledge sharing strategies.    Importantly, this research follows an iterative action research model that holds as its primary purpose the applicability and utility of results in addressing issues in the context specific to the multi-stakeholder group involved [219]. The basic methodological unit of this action research spiral is a Look-Think-Act cycle, a praxis based on sequential rounds of collaborative observation, planning, data collection and analysis. This research spiral is heavily informed by ethnographic principles that state  57 i) human behaviour and the organization of people, groups, communities and institutions are variable and are specific to local contexts, ii) understanding social, cultural and organizational dynamic is an inductive and creative process driven by local experience and perspectives  iii) the researcher is the primary instrument of data collection [203, 220].   The methodological nexus between ethnography and action research is the application of the research to the local context in order to first increase understanding of sociocultural dynamics in communities and institutions, and then to affect positive change in the same communities and institutions [221, 222]. This ethnographic action research is an iterative-inductive process borne on the theoretical foundations of interpretivist and constructivist theory. Interpretivism guides the researcher toward establishing theory through the process of data collection, reflection and analysis [221]. Constructivism posits that the researcher inextricably co-contributes to the dialectic-hermeneutic dynamic that is specific to the local context through experiences and interactions among and between research collaborators and participants; that these theories and findings are constructed through relationships, perceptions, culture and social connections [203, 223-225].   In order to clearly understand social and programmatic links, perceptions and human experiences within the dynamic of participatory dengue prevention and control, there must be a bridging of the disciplinary divide to include the positivist convention within which the EBS-Ecuador is situated. Positivist theory is deductive in nature, often relying on quantitative data to test an already established theory [223]. Methodological pluralism and pragmatism provide this bridge in mixed methodology which encourages eclecticism and posits that methodology ought to be chosen to best answer research questions arrived at through an organic and iterative process of observation and inquiry [226]. Participatory action research and KT targeting a complex issue with ecological,  58 biological and social factors within a large multi-disciplinary, multi-sector stakeholder universe requires an inclusive approach that values many ways of knowing, being and understanding.  3.3 Eco-Bio-Social project design The TDR-IDRC funded parent project ?Meeting capacity-building and scaling-up challenges to sustainably prevent and control dengue in Machala, Ecuador? is part of a multi-country three-year project to investigate the ecological, biological and social factors that contribute to and determine the presence of the mosquito vector Aedes aegypti and dengue virus transmission [227]. The overall project design is two-phase: 1) a situational analysis must be undertaken to understand these ecological, biological and social dynamics in order to 2) design and implement a participatory intervention targeted principally to address these explored dynamics. Specifically, the intervention phase of the EBS-Ecuador will comparatively evaluate two dengue prevention and control programs; i) a conventional, responsive, vertical program and ii) a newer integrated participatory approach relying on community-based action, practical child education, mosquito larval habitat reduction and larvicide [222]. The methodology of this thesis is nested within the social arm of the overall EBS-Ecuador project design contributing to both the situational analysis and implementation/evaluation phases (see Appendix 1 for a more in-depth description of EBS-Ecuador project methodology).   The situational analysis phase of the EBS-Ecuador project included a household survey in each of the 2000 participant homes administered in person to a member of the household over the age of majority by a trained vector control worker to collect basic demographic data as well as information on dengue infection history, socioeconomic status, housing conditions, access to public works (sanitary) infrastructure, water use and storage behaviours, knowledge levels regarding dengue fever and dengue virus transmission, dengue prevention behaviours in the home and access to health and vector control services. An addendum to this survey was used to collect more in-depth information regarding  59 financial autonomy of the household, migration history and ethno-cultural heritage. Entomological surveys were also carried out within each household and in public spaces; the surveys counted containers, identified container types, presence of water and presence of larval and pupal stages of the vector Ae. aegypti in those containers. Community meetings, informed consent and the first surveys were carried out from 7 Feb ? 14 April 2011. The survey instruments were developed based on instruments developed by the TDR team in a previous multi-country EBS dengue prevention and control study in Asia [119, 228], that were adapted to the context of the Latin America and the Caribbean WHO region (LAC) through two participatory workshops of the TDR EBS-LAC Community of Practice in Antigua, Guatemala (July 2009) and Guadalajara, Mexico (October 2010). The EBS-Ecuador project design provides a gross evaluation framework for the intervention-control comparison of four basic categories, Cost, Efficacy, Acceptability and Sustainability, and three basic stakeholder groups, Community, Government and Researchers.   3.3.1 Study area and participant groups Machala is a city of 245,972 people situated at 3.2667?S, 79.9667?W and 4 m above sea level on the Southwestern Pacific coast of Ecuador [119]. The climate is tropical with an average temperature of 25?C, average humidity of 90%, and average annual rainfall of 713.28 mm. The rainy season is normally from November to April and the dry season from May to October, however, local climate trends have become increasingly variable and in recent years rainy periods have become more common during dry seasons [219].   Twenty clusters consisting of approximately 250 houses each were selected from a geographic map of Machala using a random number generator to participate in the randomized controlled cluster trial of the EBS-Ecuador project. The household is considered the basic unit of data collection and analysis; 100 of the 250 homes in each cluster were enrolled in the study with informed consent resulting in a total of 2000 participant households. These 20 clusters correspond  60 closely to 20 neighbourhoods in Machala and were randomized to intervention and control treatments (Table 6).   Table 6 ? Participant neighbourhoods with assigned cluster numbers and treatment randomization Cluster Neighbourhood Treatment Cluster Neighbourhood Treatment 1 24 de Julio Control 11 3 de Noviembre Intervention 2 Sim?n Bol?var Control 12 Sauces #1 Intervention 3 Martha Bucaram Intervention 13 Manuel Encalada Control 4 9 de Octubre Intervention 14 25 de Junio Intervention 5 24 de Mayo Intervention 15 Velasco Ibarra Control 6 18 de Octubre Intervention 16 El Bosque 4 Control 7 Asoc Emplea Municip Control 17 24 de Septiembre Control 8 Central Control 18 7 de Marzo Control 9 Venezuela Intervention 19 Mario Minuche Intervention 10 Luz de Am?rica Intervention 20 El Retiro Control  3.4 Ethnography: A window on social determinants of health Ethnography is a qualitative scientific method for gathering information about and describing human experiences, relationships and. The core concept of ethnographic research holds that ways of being, living, learning, working and making meaning are specific to place, space and context, and vary from person to person [229]. Following this foundational assumption of complexity and depth of experience, ethnographic observation and description are methodological tools engineered for open discovery. Ethnographic interpretation of actions, social structures, behaviours and issues must primarily be based on a deeper understanding the lived experiences of those who are most involved or affected, and secondarily upon the experience, training and preparation of the ethnographer [221, 228, 230]. These two elements are intimately linked because the ethnographer is the primary instrument for the collection, description, documentation and analysis of experiences to construct and interpret a representation of observable phenomena. Ethnographers bring their own voice and narrative to their practice, they shape and in turn are shaped by their  61 ethnographic work creating an iterative, reflexive process seeded through participation (close or distant) in the phenomena that drive the research [221, 230, 231].  Advocacy ethnography, a relatively new term and orientation within the field, invokes the practices of critical ethnography, research reciprocity and activism research; all of which come together to facilitate a focused ethnographic contribution to critical praxis in the transformative emancipatory paradigm [232]. Research addressing the social determinants and social determination of health must be anchored in the daily experiences and realities of those who are affected by the systematic denial of their right to human security, political agency, self-determination, resources, services, and dignity [231]. Ethnography provides a context within which to systematically explore the difficult to measure effects of structures, policies, programs and practices that perpetuate health inequities and create harm.  3.4.1 Ethnographic field methods Exploratory participant observation was undertaken in a series of field visits to Ecuador, spending time in both Quito and Machala, totaling 50 weeks: 7 June ? 28 July 2010 (7 weeks), 16 January ? 23 March 2011 (9 weeks), 31 May ? 2 Sept 2011 (14 weeks), 7 January ? 13 April 2012 (14 weeks), 30 September ? 18 October 2012 (3 weeks), and 10 April ? 1 May 2013 (3 weeks). Daily observation, field notes recording, document collection, learning local dialect and forming relationships with members of all stakeholder groups began as part of the initial orientation visit (7 June ? 28 July 2010) and continued throughout the timeframe of the project. Regular cycles of community meetings in each of the 20 EBS-Ecuador project participant neighbourhoods also contributed to longitudinal relationship building and ethnographic observation over the life of the project, as well as a large EBS-Ecuador project meeting event was held 27 February 2012 in Machala that brought 170 stakeholders together from all stakeholder groups. Field notes and collected documents were organized and refined during the data cleaning and analysis stages of this study and were used in conjunction with  62 interview and focus group transcripts for the social analysis and writing of vignettes explored in Chapter 4 of this thesis. The vast majority of project activities and community interactions were done in Spanish, as it is the dominant spoken and written language in Machala. As such, field notes, collected documents, conversations, interviews, focus groups and transcripts were Spanish-language, dictating that the working language for the analyses of this study was also Spanish. I only translated the excerpts and quotes used in this thesis to English for the purposes of reporting to a primarily English-language academic audience. 3.4.2 Self-ethnographic reflections The nature of this study, as well as the nature of my involvement in the EBS-Ecuador project, dictated that its undertaking and that of the overall project were done in conjunction; the value of this work is that it is embedded in the processes of participatory global health research, program design and development, evaluation, knowledge translation and policy-making. As such, the research described in this thesis is a product of my involvement both as a PhD student tackling a specific aspect of, and as an international research coordinator for the EBS-Ecuador project. Over the life of the EBS-Ecuador project I have represented ?our country? at all of the workshops for Principal Investigators of the TDR-IDRC Latin America and Caribbean Community of Practice for Innovative Ecosystem Management of Dengue and Chagas Prevention (EBS-LAC CoP) meetings to report on and evaluate completed or in-progress work, and to design and develop next steps and subsequent research cycles (Guadalajara MX 2010, M?rida MX 2011, Fortaleza BR 2012). Through these workshops, the EBS-Ecuador project was developed with the influence of a multi-country community of practice (Bras?l, Colombia, Cuba, Ecuador, M?xico, Uruguay) within which our own bi-national collaboration (Ecuador, Canada) formed working partnerships that shaped the various processes involved in conceptualization, design, development, operationalization, evaluation, and reporting.   63 My time in Machala, 2 ? of the last four years spread over several lengthy field visits, was dedicated to the undertaking of the overall EBS-Ecuador project and to the research presented in this thesis. Both my Bachelor of Science (Hon.) and Master of Science degrees addressed the public health issue of mosquito borne disease through the lens of entomology, vector ecology and mosquito control. West Nile virus research in Manitoba from 2000 to 2004, and then Aedes aegypti and Dengue virus research in Vancouver and Tapachula, MX from 2005 - 2008, situated my expertise firmly in the technical realm of entomological and related environmental dengue risk reduction for the purposes of dengue prevention at the community level. Fortunately, this meager preparation was useful and accommodated within the infinitely larger and deeper expertise of the teams at the Machala Office for the National Service for the Control of Arthropod-borne Diseases (SNEM), the provincial (El Oro) and regional (Machala) Ministry of Health (MoH) Areas, and the participating communities of Machala. The embedded nature of my thesis research required ethnographic observation and the passive and active gathering of opinions, experiences and impressions from a wide and diverse stakeholder universe. To this end, many of my field notes and observations, as well as realms of understanding and theories arising from them, were born of my involvement in activities dedicated to the EBS-Ecuador project; they were not the result of orchestrated interactions specifically for ?ethnography? that would have defeated the purpose of the methodology. Passive data collection, then, was dependent on the activities and efforts of the overall project; active data collection via surveys, interviews, focus groups, meetings and questionnaires was varied.  I would be remiss if I did not critically examine, at least in part, the nature of my ?embeddedness? and collaboration relationship with the EBS-Ecuador project and the effects it may have on research and engagement within the context of participatory dengue prevention and control research in Machala through global research partnerships. Firstly, the interdisciplinary nature of my PhD research is of primary importance to the way the study presented in this thesis has taken  64 shape. As discussed above, my formation preceding this research had been primarily based in the positivist approach of basic sciences ? laboratory biology framed within the context of investigating ecological and evolutionary mechanisms that support conventional causal understandings of vector-borne disease. A growing personal dissatisfaction with what I perceived to be a well-meaning yet ultimately ineffectual approach to addressing complex the human health issues of vector-borne diseases lead to the active pursuit of strategies that had the potential to address the glaring issues of inequity that clearly contribute to the persistence of poor health (including vector-borne disease) in neighbourhoods the world over. Theory, literature, and story from Paolo Friere, Paul Farmer, Fidel Castro, Ernest Stringer, Amartya Sen, Bob Evans and the Zapatista movement compelled me toward considering non-medical determinants of health, the production of harm through macro-level neo-liberalist and extractive economic policy, and the importance of addressing inequitable power-sharing (or not sharing) as the places from where promising strategies may be developed. This deliberate paradigmatic and disciplinary shift was, in a very real sense, driven by a palpable sense that I had been participating in a disempowering dynamic that mainly served the people involved who were not actually affected by disease transmission risk (including myself).   This thesis represents my first foray into formal qualitative research and, in particular, to engaging with social, cultural and political dynamics in Latin America, Ecuador, El Oro and Machala in order to challenge the systems of influence that determine the presence of dengue vectors, dengue fever transmission risk and the persistence of dengue fever and severe dengue in Machalan neighbourhoods. Therefore, I have chosen to engage with this complex and interconnected web of people, environment, interactions and governance through the lens of what I see as the intersection of constructivism/interpretivism, critical pedagogy, participatory action research and social determinants of health. The questions that I had when beginning this work were: Who are the people that are involved in and affected by dengue in  65 Machala? How do their human experiences differ and how might that shape the way they interface with dengue and dengue-related harms? Are they hopeful that the harm they experience in their daily lives caused by systems of influence can be healed/stopped/reduced? How do they feel/what do they think about global health research as a mechanism for positive change? What is their history and imagined future as it pertains to participatory, community-based and community-driven work to address inequities and to improve health and well-being in their own lives, homes, neighbourhoods and larger communities? How can global health research contribute to transformative emancipatory work with communities to address dengue and dengue-related harms, while simultaneously critically examining its own contribution to those harms? And finally, should I as a white Canadian graduate student (with all of the particularities of my own culture, history and orientations and their implications within global systems of influence and harm) seek to undertake this work; and if I do, what will that look like?  Essentially, my approach to the research described in this thesis was heavily influenced by the goal of meaningfully participating within a learning organization; one that addresses challenges through building on locally generated experience and knowledge to work toward addressing an identified issue (bottom-up and iterative, equitable approaches geared toward inclusion and appreciating richness in diverse knowledge) rather than transmitting pre-defined problems and their solutions for implementation in a chosen geopolitical coverage area. The theoretical and methodological choices of the constructivist/interpretivist approach with an emphasis on social justice, equitable participation and community-based approaches supported this general approach and allowed the resear