Resisting control of neglected tropical diseases: dilemmas in the mass treatment of schistosomiasis and soil-transmitted helminths in north-west Uganda

A strong case has recently been made by academics and policymakers to develop national programmes for the integrated control of Africa’s ‘neglected tropical diseases’. Uganda was the first country to develop a programme for the integrated control of two of these diseases: schistosomiasis and soil-transmitted helminths. This paper discusses social responses to the programme in Panyimur, north-west Uganda. It shows that adults are increasingly rejecting free treatment. Resistance is attributed to a subjective fear of side-effects; divergence between biomedical and local understandings of schistosomiasis/bilharzia; as well as inappropriate and inadequate health education. In addition, the current procedures for distributing drugs at a district level are problematic. Additional research was carried out in neighbouring areas to explore the generalizability of findings. Comparable problems have arisen. It is concluded that the national programme will not fulfil its stated objectives of establishing a local demand for mass treatment unless it can establish more effective delivery strategies and promote behavioural change in socially appropriate ways. To do so will require new approaches to social, economic and political aspects of distribution. There are reasons why populations infected with the ‘neglected tropical diseases’ are themselves neglected. Those reasons cannot just be wished away

Rumours and riots: Local responses to mass drug administration for the treatment of neglected tropical diseases among school-aged children in Morogoro region, Tanzania

This thesis was submitted for the degree of Doctor of Philosophy and was awarded by Brunel UniversityIn August 2008, a biomedical intervention providing free drugs to school aged children to treat two endemic diseases –schistosomiasis haematobium and soil-transmitted helminths - in Morogoro region, Tanzania, was suspended after violent riots erupted. Parents and guardians rushed to schools to prevent their children taking the drugs when they heard reports of children dying in Morogoro town after receiving treatment. When pupils heard these reports, many of those who had swallowed the pills began to complain of dizziness and fainted. In Morogoro town hundreds of pupils were rushed to the Regional Hospital by their parents and other onlookers. News of these apparent fatalities spread throughout the region, including to Doma village where I was conducting fieldwork. Here, protesting villagers accused me of bringing the medicine into the village with which to “poison” the children and it was necessary for me to leave the village immediately under the protection of the Tanzanian police. This thesis, based on eleven months fieldwork between 2007 and 2010 in Doma village and parts of Morogoro town, asks why was this biomedical intervention so vehemently rejected? By analysing local understandings and responses to the mass distribution of drugs in relation to the specific historical, social, political, and economic context in which it occurred, it shows that there was a considerable disjuncture between biomedical understandings of these diseases, including the epidemiological rationale for the provision of preventive chemotherapy, and local perspectives. Such a disjuncture, fuelled by the reports of fatalities and the pupil’s fainting episodes brought about considerable conjecture both locally and nationally, that the drugs had been faulty, counterfeit, or hitherto untested on humans. Among many of the poorer inhabitants of Morogoro town, there was suspicion that this had been a covert sterilization campaign. From an official perspective, such conjecture was dismissed as mere rumour, proliferated by “ignorant” people. However, from an anthropological perspective, these ‘rumours’ reveal profound local anxieties including a pervasive fear that poor Africans are being targeted for covert eugenics projects by governments in the industrialized world. The thesis also shows that many of the assumptions embedded in global policies seeking to control neglected tropical diseases are mistaken. Indeed, it is suggested that it is unlikely that schistosomiasis haematobium and soil-transmitted helminths will be controlled so long as policy makers persist with the idea that one policy, designed by staff working for the World Health Organisation – with minor modifications added in Dar es Salaam - can be rolled out uniformly, irrespective of the political, social and economic context in which the programme occurs

Poster boys and the rehabilitative dream: using a temporal lens to explore severe brain injury rehabilitation

Context: The future comes into the present and acts upon the now. Understanding how engagement with the future shapes today and how actions taken in the now affect a time yet to come is important in understanding and improving brain injury rehabilitative practice. Objective: This paper examines the way in which futures of different types of brain-injured residents residing in long-term neurological care settings are imagined by health and care professionals and the role a ‘rehabilitative imaginary’ has in how residents’ futures are imagined or go unimagined. Methods: Over 500 hours of ethnographic observations and 49 interviews with staff members in two neurological rehabilitation and long-term settings in England were analysed using situational analysis, drawing out key rehabilitative narratives presented here. Findings: Residents were primarily categorised by their abilities to rehabilitate successfully (or not) and their futures imagined (or not) in line with their rehabilitative journey. Key residents who successfully rehabilitated and fulfilled a rehabilitative ideal were held up as ‘poster boys’ (or girls), providing a positive advertisement for the organisation, engendered dedication to the specialism of neurological rehabilitation and reinforced rehabilitation-as-process. Limitations: Data was collected in two English care settings. Applicability to international care settings is unknown. Extraneous factors restricting health care professionals’ future imaginings were not explicitly studied. Implications: The paper concludes by considering the implications of rehabilitative imaginary-fuelled narratives in these settings. It argues that predominant rehabilitative narratives bracket out how and if the futures of those unable to rehabilitate successfully are imagined by health care professionals and questions whether non-imagining leads to inaction around those not rehabilitating. Potential organisational and structural reasons for constrained health care professionals’ imaginings is discussed, and broader applicability of the reification of particular patient types in other areas of health care is considered

An Examination of Educational Policies for Students with Type 1 Diabetes in Catholic School Boards

With 1 in 300 children having diabetes, Type 1 Diabetes (T1D) is one of the most common chronic illnesses affecting school age children (Kelo, Martikainen & Eriksson, 2011; Kucera & Sullivan, 2011; Lawrence, Cummings, Pacaud, Lynk & Metzger, 2015). If not managed properly, T1D can drastically affect a student’s ability to experience academic success. Diabetes Canada, formerly known as the Canadian Diabetes Association, has a set of guidelines that they recommend each school board incorporate into their policies for the management of T1D. The authors analyzed fifteen Ontario Catholic school boards’ policies pertaining to T1D to determine if the policies address Diabetes Canada’s guidelines. Out of the fifteen school boards analyzed, only four school boards had a T1D policy. A policy analysis was then conducted on the four policies to determine whether the policies met the guidelines set out by Diabetes Canada. The four policies were found to be lacking in the areas of educating staff about T1D and assisting students during hypoglycemic episodes. It is recommended that a standardized Ministry policy be developed that addresses the guidelines outlined by Diabetes Canada

Type 2 Diabetes Education Programmes - Focusing on Patient's Perceptions

ObjectiveThe prevalence of Type 2 Diabetes in the UK during 2013 was 0.6%, equating to 3.2 million people. Forecasts indicate that three people will be diagnosed every ten minutes by 2025. Ineffective methods or delays in thorough patient education leaves the patient at risk of developing foot complications among wider issues of morbidity. This research aimed to test the efficacy of patient education for Type 2 Diabetes by analysing patients’ views following their educational programme. The project aimed to highlight the value of such education programmes and to encourage wider holistic awareness of education in patient management.MethodWith School of Health ethical committee approval, a focus group was formed using a random sample of seven consenting Podiatry patients from a UK School of Podiatry. All patients had a diagnosis of Type 2 Diabetes and had attended an educational programme at some point over the last 12 years. The researcher initiated discussion with questions to the group and a one hour discussion was transcribed. This was defined using Nvivo 10 software and thematic analysis was employed to look at quality, recurrent themes and their significance in relation to the existing evidence base. The primary outcome measure was comprehension. Positive and negative perceptions were defined into subthemes to measure specific outcomes.OutcomeThis qualitative research study considered the efficacy of educational programmes for patients with a diagnosis of Type 2 Diabetes, using patients’ perceptions. Contexts around stabilisation of glucose levels, quality of life, patient adherence and relationships were analysed. Although diet was quantifiably discussed, reference to comprehension and consistency of patient education were defined in order to answer the research question. Compared to current evidence, measures of group versus individual education, biomedical outcomes in the disease process and perceptions via questionnaires, this study found structure of education programmes to be the underlying key to successful outcomes.DiscussionEffectual education is reliant upon collaborative interventions of all Health Care Professionals, so that consistent information is delivered and patients get the practical skills required to self-manage their Diabetes. Furthermore, patients’ knowledge of their condition plays a valuable adjunct to basic awareness of Diabetic foot disease. Though there are many programmes available, it is evident that some patients newly diagnosed and some with long standing Type 2 Diabetes have limited knowledge of their condition. They feel anxious and confused, however; the majority of patients embrace the chance to share their story and knowledge, feeling empowered upon doing this.This study has served as a useful pilot study and compared existing literature with the presenting qualitative evidence, however; for future research in this area a wider study is recommended to further investigate patient trends in a larger population. Moreover recommended are all practitioners involved ensure patient education forms part of a treatment plan and that we ensure, as professionals, we constantly question our practice. How do we educate best, and are the messages consistent in our delivery of patient education

Caring relations at the margins of neurological care home life: the role of 'hotel service' staff in brain injury rehabilitation

Context: Domestic staff in hospitals and aged long-term care have been shown to perform a range of caring roles alongside their cleaning work. Objective: This paper explores the roles these people and other ‘hotel service staff’ (catering, domestic, maintenance, finance and administrative) play in the rehabilitation of people with brain injuries residing in long-term care settings. Methods: This research draws on in-depth ethnographic data collected in 2014–15 over five months at two neurological long-term care settings in the UK; including interviews and observations of day-to-day happenings in the lives of around 60 brain injured residents and the work of 16 hotel service staff. The data was subject to a situational analysis – underpinned by grounded theory and discourse analysis. Findings: Hotel service staff contribute to and compliment the rehabilitation of patients’ cognitive skills, communication and physical functioning, and provide opportunities for occupation and interaction. The therapeutic accomplishments achieved by involving patients in mundane tasks of everyday life (e.g., gardening, managing money, sharing food), fit with the aims of more ‘formalized’ rehabilitation – to restore patients’ abilities to carry out ‘activities of daily living’. Limitations: This study has been unable to fully explicate how hotel service staff have, or gain, the skills to interact so positively with brain injured residents. The study was confined to two sites and may not be reflective of practice elsewhere. Implications: The study findings highlight how the work and interactions of hotel service staff contribute not only to care but to the rehabilitation of people with severe brain injuries. This has implications for service design as well as health and social care education

Caring for people with severe brain injuries: improving health care professional communication and practice through online learning

Introduction: Severe brain injuries can leave people in prolonged disorder of consciousness resulting in multifaceted medical, nursing, and rehabilitative needs that can be challenging for even the most experienced multidisciplinary team. The complexities of care, communication with families, and best interest decision-making about medical interventions means there is a need for ongoing training in clinical, social, ethical, and legal aspects. Methods: Using a combination of group discussions, interviews, and questionnaires with learners, this article reports an evaluation of designing and delivering an interprofessional, online work-based course to health care professionals caring for prolonged disorder of consciousness patients. Results: There were challenges for staff uptake because of COVID-19, but engaging with it increased knowledge in defining and diagnosing patients' conditions, understanding multidisciplinary team roles, communicating with families, and navigating legal and ethical issues. Course participation also enhanced critical and reflective thinking skills, provided a sense of connection to other professionals, and generated plans to improve service provision. Discussion: Online learning that enables health care professionals to engage at their own pace and also come together as an interprofessional community can provide invaluable continuing professional development and help to enhance joined up, holistic patient care. However, achieving this requires significant investment in creating research-led, multimedia, learning materials, and courses that include synchronous and asynchronous delivery to combine flexible study with the opportunity for peer networks to form. It also depends on a commitment from organizations to support staff online continuing professional development. In response to the COVID-19 pandemic, most forms of continuing professional development (CPD) for health care professionals (HCPs) had to move rapidly online. Since then, National Health Service (NHS) and health education strategies1 have prompted further strategic thinking about how to move beyond emergency online delivery to a more sustainable and positive engagement with the potential of online CPD. This article evaluates a multimedia online course designed to develop HCPs' skills in caring for patients with prolonged disorders of consciousness (PDoC). Prolonged disorders of consciousness is an umbrella term for three conditions—coma, vegetative, and minimally conscious states. These conditions, caused by severe brain injury, are associated with profound motor, cognitive, sensory, and functional deficits that require full and continuous care.2 The complexity of such patients' needs is complicated further by social, ethical, and legal contexts. Our own research has highlighted urgent training requirements for HCPs including clarification around diagnosis, improving communication with families, and enhancing decision-making about life-sustaining interventions.3–7 In a bid to address these learning needs, we (members of the Coma and Disorders of Consciousness Research Centre) had already delivered in-person talks and training days to over 5000 practicing HCPs since our formation as a research center in 2010 (see list at: www.cdoc.org.uk). In 2018, we started to develop an online learning course designed to be delivered over a ten-week period for interprofessional CPD in workplace settings, combining online interactive self-study modules with “real-time” virtual seminars and tweet chats. The course consists of three learning sets, each involving two or three modules (Table 1); each set involves between four and 8 hours of independent study, depending on the learner's knowledge base and the depth to which they wish to explore each area

Inhibition of delta-like ligand 4 induces luteal hypervascularization followed by functional and structural luteolysis in the primate ovary

Using specific inhibitors established that angiogenesis in the ovarian follicle and corpus luteum is driven by vascular endothelial growth factor. Recently, it has been demonstrated that the Notch ligand, delta-like ligand 4 (Dll4) negatively regulates vascular endothelial growth factor-mediated vessel sprouting and branching. To investigate the role of Dll4 in regulation of the ovarian vasculature, we administered a neutralizing antibody to Dll4 to marmosets at the periovulatory period. The vasculature was examined on luteal d 3 or d 10: angiogenesis was determined by incorporation of bromodeoxyuridine, staining for CD31 and cell death by staining for activated caspase-3. Ovulatory progesterone rises were monitored to determine effects of treatment on luteal function and time to recover normal cycles in a separate group of animals. Additionally, animals were treated in the follicular or midluteal phase to determine effects of Dll4 inhibition on follicular development and luteal function. Controls were treated with human IgG (Fc). Corpora lutea from marmosets treated during the periovulatory period exhibited increased angiogenesis and increased vascular density on luteal d 3, but plasma progesterone was significantly suppressed. By luteal d 10, corpora lutea in treated ovaries were significantly reduced in size, with involution of luteal cells, increased cell death, and suppressed plasma progesterone concentrations. In contrast, initiation of anti-Dll4 treatment during the midluteal phase produced only a slight suppression of progesterone for the remainder of the cycle. Moreover, Dll4 inhibition had no appreciable effect on follicular development. These results show that Dll4 has a specific and critical role in the development of the normal luteal vasculature

Disentangling trophic interactions inside a Caribbean marine reserve

Author Posting. © Ecological Society of America, 2010. This article is posted here by permission of Ecological Society of America for personal use, not for redistribution. The definitive version was published in Ecological Applications 20 (2010): 1979–1992, doi:10.1890/09-1217.1.Recent empirical studies have demonstrated that human activities such as fishing can strongly affect the natural capital and services provided by tropical seascapes. However, policies to mitigate anthropogenic impacts can also alter food web structure and interactions, regardless of whether the regulations are aimed at single or multiple species, with possible unexpected consequences for the ecosystems and their associated services. Complex community response to management interventions have been highlighted in the Caribbean, where, contrary to predictions from linear food chain models, a reduction in fishing intensity through the establishment of a marine reserve has led to greater biomass of herbivorous fish inside the reserve, despite an increased abundance of large predatory piscivores. This positive multi-trophic response, where both predators and prey benefit from protection, highlights the need to take an integrated approach that considers how numerous factors control species coexistence in both fished and unfished systems. In order to understand these complex relationships, we developed a general model to examine the trade-offs between fishing pressure and trophic control on reef fish communities, including an exploration of top-down and bottom-up effects. We then validated the general model predictions by parameterizing the model for a reef system in the Bahamas in order to tease apart the wide range of species responses to reserves in the Caribbean. Combining the development of general theory and site-specific models parameterized with field data reveals the underlying driving forces in these communities and enables us to make better predictions about possible population and community responses to different management schemes.This work was supported by funding from the Bahamas Biocomplexity Project (U.S. NSF Biocomplexity grant OCE-0119976) and U.S. EPA Science to Achieve Results (R832223)