How can malaria rapid diagnostic tests achieve their potential? A qualitative study of a trial at health facilities in Ghana.

BACKGROUND: Rapid diagnostic tests (RDTs) for malaria are at the early stages of introduction across malaria endemic countries. This is central to efforts to decrease malaria overdiagnosis and the consequent overuse of valuable anti-malarials and underdiagnosis of alternative causes of fever. Evidence of the effect of introducing RDTs on the overprescription of anti-malarials is mixed. A recent trial in rural health facilities in Ghana reduced overprescription of anti-malarials, but found that 45.5% patients who tested negative with RDTs were still prescribed an anti-malarial. METHODS: A qualitative study of this trial was conducted, using in-depth interviews with a purposive sample of health workers involved in the trial, ranging from those who continued to prescribe anti-malarials to most patients with negative RDT results to those who largely restricted anti-malarials to patients with positive RDT results. Interviews explored the experiences of using RDTs and their results amongst trial participants. RESULTS: Meanings of RDTs were constructed by health workers through participation with the tests themselves as well as through interactions with colleagues, patients and the research team. These different modes of participation with the tests and their results led to a change in practice for some health workers, and reinforced existing practice for others. Many of the characteristics of RDTs were found to be inherently conducive to change, but the limited support from purveyors, lack of system antecedents for change and limited system readiness for change were apparent in the analysis. CONCLUSIONS: When introduced with a limited supporting package, RDTs were variously interpreted and used, reflecting how health workers had learnt how to use RDT results through participation. To build confidence of health workers in the face of negative RDT results, a supporting package should include local preparation for the innovation; unambiguous guidelines; training in alternative causes of disease; regular support for health workers to meet as communities of practice; interventions that address negotiation of health worker-patient relationships and encourage self-reflection of practice; feedback systems for results of quality control of RDTs; feedback systems of the results of their practice with RDTs; and RDT augmentation such as a technical and/or clinical troubleshooting resource

Glaucoma, "the silent thief of sight": patients' perspectives and health seeking behaviour in Bauchi, northern Nigeria.

BACKGROUND: In Nigeria, glaucoma has a high prevalence and is the second cause of blindness among adults after cataract. People with glaucoma frequently present very late with advanced disease, and acceptance of and adherence to treatment is low. The purpose of the study was to explore how patients' understand and respond to glaucoma in order develop an intervention to improve adherence to treatment. METHOD: Hospital based qualitative study. Six focus group discussions were held with patients with advanced disease and who had either undergone glaucoma surgery, were receiving medical treatment, or had neither surgery nor medical treatment. Two traditional healers who treat eye conditions were interviewed. Audio files were transcribed, translated into English and recurring themes coded and categorized as the impact of vision loss, and understandings of the disease and its management. RESULTS: Visual loss impacted significantly on the lives of people with glaucoma in many ways. Many heard the term "glaucoma" for the first time during the study. Local terms to describe the symptoms included Hawan jinin ido ("hypertension of the eye"). Patients sought treatment in pharmacies, or with traditional healers who had different interpretations of glaucoma and its treatment to biomedical understandings. Cost and forgetfulness were the main reasons for low adherence to treatment while fear was a reason for not accepting surgery. Lack of money and negative staff attitudes were reasons for low follow up. CONCLUSION: Halting the progression of glaucoma is possible with treatment but the condition will remain a "silent thief of sight" in West Africa unless awareness, uptake of services and adherence to treatment improve. Understanding how glaucoma is locally conceptualised, lived with and responded to by patients is essential to aid the design of interventions to prevent glaucoma blindness in Africa. Findings have been used to adapt a motivational interviewing intervention, which is being evaluated in a clinical trial

Opening up ‘fever’, closing down medicines

Rising concerns about antimicrobial resistance have sparked a renewed push to rationalise and ration the use of medicines. This article explores the case of the Integrated Management of Childhood Illness (IMCI) guideline, a periodically updated ‘global’ algorithm that shapes and normalises the centrality of medicines to care in low- and middle-income countries and, increasingly, the imperative to ration them. Using ‘classification work’ as analytic frame, we firstly consider the IMCI algorithm as a blueprint for global health that classifies illnesses, patients, and care in particular ways relative to available medicines. Zooming in on this blueprint, we then offer a classificatory reading of ‘fever’ over time, tracing ‘nonmalarial fever’ from being malaria’s residual ‘other’ category to becoming increasingly legible through attention to diagnostics and antibiotic (over)use. Our reading suggests that an apparent refinement of the ‘fever’ category may concurrently entail the closing down of medicine options. This raises the possibility that an increasingly high-tech but ‘empty’ form of pharmaceuticalised care is being incidentally worked into the infrastructure of weak health systems

Quick fix for care, productivity, hygiene and inequality:Reframing the entrenched problem of antibiotic overuse

Antimicrobial resistance (AMR) is a major challenge of our time. A key global objective is to reduce antibiotic use (ABU), in order to reduce resistance caused by antimicrobial pressure. This is often set as a 'behaviour change' issue, locating intervention efforts in the knowledge and attitudes of individual prescribers and users of medicines. Such approaches have had limited impact and fall short of addressing wider drivers of antibiotic use. To address the magnitude of antibiotic overuse requires a wider lens to view our relationships with these medicines. This article draws on ethnographic research from East Africa to answer the question of what roles antibiotics play beyond their immediate curative effects. We carried out interviews, participant observation and documentary analysis over a decade in northeast Tanzania and eastern and central Uganda. Our findings suggest that antibiotics have become a 'quick fix' in our modern societies. They are a quick fix for care in fractured health systems; a quick fix for productivity at local and global scales, for humans, animals and crops; a quick fix for hygiene in settings of minimised resources; and a quick fix for inequality in landscapes scarred by political and economic violence. Conceptualising antibiotic use as a 'quick fix' infrastructure shifts attention to the structural dimensions of AMR and antimicrobial use (AMU) and raises our line of sight into the longer term, generating more systemic solutions that have greater chance of achieving equitable impact

Protocol: WASH and biosecurity interventions for reducing burdens of infection, antibiotic use and antimicrobial resistance: a One Health mixed methods systematic review

Antimicrobial resistance (AMR) is a growing global problem. Like many other public health issues, research points to the important role of structural factors in shaping the emergence, transmission and burden of AMR. However, mirroring other areas of public health, the evidence-base of interventions that address these structural issues is slim and infrequently synthesised. Structural interventions (SIs) seek to alter the context that produces or co-produces ill-health4. AMR has been configured as a One Health problem to be understood in terms of human-animal-environment interconnections. Infection control and prevention is recognised as essential to addressing AMR, but how best to achieve this through a One Health perspective remains a challenge. This review addresses this gap by identifying and synthesising evidence of interventions that operate on a structural level to Improve water, hygiene, sanitation and biosecurity in communities that live and/or work with animals In Low- and Middle-Income Countries (LMICs). The premise of this review is that interventions to improve water, sanitation, hygiene (WASH), and biosecurity intend to reduce burdens of infection and have the potential to reduce reliance on antibiotics for humans and animals. Therefore, such interventions have the ability to reduce both transmission and emergence of AMR. Two further observations inform the focus of this review: growing evidence of the insufficiency of purely technical or behavioural WASH/biosecurity Interventions to reduce disease burdens across LMICs, accompanied by calls for structural Interventions; and that most reviews retain classificatory silos of either human WASH or animal biosecurity which belies the realities of many rural and urban populations whose lives are interconnected with animals across LMIC settings. This review, therefore, addresses the potential for structural interventions on WASH/biosecurity to have an impact on Infections, antibiotic use and AMR in LMICs. Methodologically, this review is influenced by impact assessments in development studies, where interventions are often complex in design and implementation and their effects multifaceted. The kinds of intervention that operate at a structural level are similarly challenging to identify and to characterise neatly, and are unlikely to be restricted to a randomised controlled trial design. Therefore, our search criteria and strategy are wide and our methods mixed, in order to capture potential interventions that could have an impact on our set of outcomes. In addition, in this review we recognise that interventions have impacts beyond a particular pre-defined outcome, and to be able to recommend a particular intervention strategy requires consideration of not only what that intervention comprised and required, but also what unintended consequences or co-benefits the intervention may have produced. Finally, a key consideration for this review is that many studies undertaken in Spanish, Portuguese and French speaking countries, where different interventions may have been developed and piloted, can be excluded due to language criteria, and in this case, we deliberately include studies in these languages in addition to English in the search and review. This systematic review will summarise evidence on how WASH and biosecurity interventions could have the potential to reduce the burden of infections, antimicrobial use and/or AMR in animal agriculture and in people in contact with animals in different country settings, with a focus on LMICs. WASH and biosecurity interventions for reducing burdens of infection, antibiotic use and antimicrobial resistance: a One Health mixed methods systematic review Included studies have to examine the impact of WASH and biosecurity interventions on reducing burden of infections and therefore promote healthier production systems where the use of antibiotics is reduced or limited. Our review will categorise these interventions according to the context where they were performed (e.g., LMICs country, region, urban or rural, type of productions systems, livelihoods systems, agroecological situation, beneficiaries, climate conditions). The aim of this study is to identify points for WASH and biosecurity interventions at structural and system levels that will enable reduction in reliance on antibiotics in the everyday lives of people living with animals in urbanised and rural landscapes

Motivation, money and respect: a mixed-method study of Tanzanian non-physician clinicians.

Poor quality of care is a major concern in low-income countries, and is in part attributed to low motivation of healthcare workers. Non-physician clinicians (mid-level cadre healthworkers) are central to healthcare delivery in half of the countries in Africa, but while much is expected from these clinicians, little is known about their expectations and motivation to perform well. Understanding what motivates these healthworkers in their work is essential to provide an empirical base for policy decisions to improve quality of healthcare. In 2006-2007, we conducted a mixed-method study to evaluate factors affecting motivation, including reasons for varying levels of motivation, amongst these clinicians in Tanzania. Using a conceptual framework of 'internal' and 'environmental' domains known to influence healthworker motivation in low-income countries, developed from existing literature, we observed over 2000 hospital consultations, interviewed clinicians to evaluate job satisfaction and morale, then designed and implemented a survey instrument to measure work motivation in clinical settings. Thematic analysis (34 interviews, one focus group) identified social status expectations as fundamental to dissatisfaction with financial remuneration, working environments and relationships between different clinical cadres. The survey included all clinicians working in routine patient care at 13 hospitals in the area; 150 returned sufficiently complete data for psychometric analysis. In regression, higher salary was associated with 'internal' motivation; amongst higher earners, motivation was also associated with higher qualification and salary enhancements. Salary was thus a clear prerequisite for motivation. Our results are consistent with the hypothesis that non-salary motivators will only have an effect where salary requirements are satisfied. As well as improvements to organisational management, we put forward the case for the professionalization of non-physician clinicians

“Let me be part of the narrative” – The Schuyler Sisters ‘almost’ feminist?

Lin Manuel Miranda’s Hamilton: An American Musical (Hamilton) (2015) has tapped into the current cultural moment, lauded as the ‘saviour of Broadway’.1 The show’s unique tour de force is the use of hip-hop to convey the story, reigniting the genre and attracting a new musical theatre audience. This musical idiom combined with Hamilton’s colour conscious casting has allowed Miranda to create ‘the story of America then told by America now’2 exposing to critical view the whitewashing of history and the more questionable legacies of the Founding Fathers of America. The show is inescapable, dominating social media through its innovative #Ham4Ham and #Hamildrop initiatives.3 Television shows are even cashing in on Hamilton’s cultural currency with references to the show appearing in Brooklyn Nine Nine, Grey’s Anatomy, and Gilmore Girls (amongst others) as well as talk shows such as The Late Show. With so much exposure it is hard not to get swept up in the hype surrounding the musical

“Does Anybody Have A Map?”: The Impact of “Virtual Broadway” on Musical Theatre Composition

Song form, structure, function and ideology are culturally and genre specific. Boiled down to its most basic elements, a pop song is about emotional connection and engagement, whereas its musical theatre cousin is concerned with narrative progression; ‘pop songs are to adjectives what musical theatre songs are to verbs.’ (Lambert, 2015) Lambert articulates a binary perspective on genres, which are actually overlapping in unprecedented ways, in terms of authorship, style, means of distribution, and popularity. This paper explores, not the distinctions, but the points of contact between song forms, with a view to understanding the current creative moment, and, perhaps, anticipating future trends. In contemporary popular music, ‘There are no longer subjective gatekeepers controlling who gets let “in”, promoted and exposed. The choice is ours. Now, anyone can be famous.’ (Price, 2011). This is a transformation also evident in musical theatre, where an upsurge in ‘YouTube musical theatre composers’ (Pasek & Paul, 2015) and social media engagement challenges the dominance of the book musical. Opportunities for self-promotion on the internet are vast, and allow composers to reach a more diverse audience (or wider network), but in what ways do these emerging opportunities also influence the form of works produced. If humans on-line have an average attention span of 8 seconds (Riecke-Gonzales, 2015), for example, this paper considers how musical theatre is evolving to meet the requirements of millennials. The popularity of Dear Evan Hansen - arguably the first truly ‘digital age’ musical (Takiff, 2016)- and Be More Chill provide timely examples of the impact of ‘virtual Broadway’ (Pasek & Paul, 2015) on the musical theatre model. It is both possible and timely to debate the extent to which this hybrid has ‘democratized access to creation and distribution tools’ (Bhargava and Klat, 2017), allowing new voices and models to break through, or has actually limited the genre’s scope. As networks of influence diversify and democratise and the number of people engaging with digital Broadway rises this paper considers the next steps for musical theatre as it discovers the internet

Looking back to think forward: Feminist utopian resistance and musical theatre

Presentation delivered as part of Telephone Hour: A Quarantine Colloquium, presented by the Association for Theatre in Higher Education

Integration & Disintegration in Next to Normal

Romance and romantic entanglements are the fuel of musical theatre, igniting words and music (to paraphrase Engel and Kissel 2006:113) to create entertaining and successful shows (Knapp, 2006) with uplifting happy endings. Whilst critical exploration might expose cracks and highlight how deceptive such happy endings actually are (Kirle, 2005:2), their normative force in performance perpetuates and reinforces gender hierarchies and stereotypes: ‘Women wait for love, men bring it’ (Barnes, 2015:51).reinforces fantasies of patriarchal superiority and affirming damaging gender binaries. Next to Normal eschews the ‘marriage trope’, whereby jagged edges are smoothed by romantic union, employing instead ‘the divorce trope’ ‘in which a woman creates the sensibility of a musical by leaving an existing unworkable reality to invent herself’ (Knapp, 2016:822). Scott McMillan argues that the driving factor in musical theatre isn’t seamless integration but ‘the crackle of difference’ as the musical shifts between ‘book time’ and ‘lyric time’ (McMillan 2006). Next to Normal ‘combines its use of music with issues of visibility in order to reveal multiple views of reality’ (Donnelly, 2014:18), arguably marking a moment of transition within the musical theatre genre. The audience spends about eighty per cent of the show suspended in lyric time without the option to return to the perceived normalcy of book time, thus expanding the genre’s capabilities.’(McMillan, 2006: 22). As herstory has its eyes on musical theatre Next to Normal deserves to be lauded as the important work it is and the aftershocks it has created need to be further explored and investigated. This article reflects on the implications of engaging with Next to Normal on its own terms for pedagogical practice: in what ways might it be possible to explore through practice the critical potential of this work