Everyday geographies of belonging : young refugees and 'home-making' in Glasgow

PhD ThesisvThis thesis explores everyday geographies of belonging of young refugees living in Glasgow, Scotland. The young participants are aged between 15-25 years and have arrived in the city within the last three years. A multi-layered understanding of young refugees’ sense of belonging and ‘home-making’ in Glasgow is enabled through 18 months of fieldwork based on participant observation with two refugee organisations in Glasgow; thirty individual interviews and five group discussions with young refugees; and three participatory projects. In this thesis, I suggest that by exploring belonging through the lens of the everyday it is possible to account for young refugees’ experiences at the intersection of national politics of belonging and an emotional and embodied sense of being ‘at home’. I can thus demonstrate the ambivalent nature of belonging experienced by young refugees living in Glasgow, and render visible the constant tension between exclusionary politics of belonging shaping young people’s everyday spaces and lives, and daily practices of home making and community building. In accounting for young people’s lived realities, this thesis makes an important contribution to current scholarship, which has tended to be policy-focused, seldom providing in-depth insights into young refugees’ everyday experiences of belonging and home. This thesis follows young people’s narratives in three separate empirical chapters, which together account for the complex interplay of different dimensions and scales of belonging in young people’s lives. I begin by discussing limitations and barriers posed by national politics of belonging for young people’s ability to develop a sense of being ‘at home’ in their new environment. Having thus set the context, the remaining two chapters explore a range of different everyday practices through which young people carve out spaces and ‘communities’ of belonging in tension with these limiting circumstances. Whilst overall focusing on everyday experiences of belonging, I conclude by drawing attention to the potential of the everyday to provide a basis for - albeit almost inaudible - claims to belongin

How effective and cost-effective are behaviour change interventions in improving the prescription and use of antibiotics in low-income and middle-income countries? A protocol for a systematic review.

INTRODUCTION: Antibiotic resistance endangers effective prevention and treatment of infections, and places significant burden on patients, families, communities and healthcare systems. Low-income and middle-income countries (LMICs) are especially vulnerable to antibiotic resistance, owing to high infectious disease burden, and limited resources for treatment. High prevalence of antibiotic prescription and use due to lack of provider's knowledge, prescriber's habits and perceived patient needs further exacerbate the situation. Interventions implemented to address the inappropriate prescription and use of antibiotics in LMICs must address different determinants of antibiotic resistance through sustainable and scalable interventions. The aim of this protocol is to provide a comprehensive overview of the methods that will be used to identify and appraise evidence on the effectiveness and cost-effectiveness of behaviour change interventions implemented in LMICs to improve the prescription and use of antibiotics. METHODS AND ANALYSIS: Two databases (Web of Science and PubMed) will be searched based on a strategy developed in consultation with an essential medicines and health systems researcher. Additional studies will be identified using the same search strategy in Google Scholar. To be included, a study must describe a behaviour change intervention and use an experimental design to estimate effectiveness and/or cost-effectiveness in an LMIC. Following systematic screening of titles, abstracts and keywords, and full-text appraisal, data will be extracted using a customised extraction form. Studies will be categorised by type of behaviour change intervention and experimental design. A meta-analysis or narrative synthesis will be conducted as appropriate, along with an appraisal of quality of studies using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) checklist. ETHICS AND DISSEMINATION: No individual patient data are used, so ethical approval is not required. The systematic review will be disseminated in a peer-reviewed journal and presented at a relevant international conference. PROSPERO REGISTRATION NUMBER: CRD42017075596

"Unorthodox, troublesome, dangerous and disobedient": a feminist perspective on health economics, CHERE Discussion Paper No 33

Feminist theory has developed to explore the links between the social construction of scientific disciplines and the social construction of gender (Ferber and Nelson, 1993). The critique of economic theory is a more recent application of feminist theory. Many feminist economists have examined issues of gender bias within neoclassical economics. It is the aim of this discussion paper to outline this feminist critique of economics, particularly neoclassical economics, and to discuss its relevance to health economics. The feminist critique is relevant to health economics for a number of reasons. Health economics draws upon theories developed in other areas of economics such as finance and insurance, industrial organisation, labour and public finance. Therefore, many of the gender related criticisms applied to the discipline of economics can be extended to health economics. It is also relevant simply because women represent the main labour force within health , are the majority of unpaid producers of health care and health, and are the principal consumers of market provided health care. The paper examines how three key assumptions in neoclassical economics have been applied in health economics: the idea of the separative self, the single maximand and the benchmark of perfect competition. It is argued that while the idea of market failure is more central to health economics than to other areas of economics, these key assumptions are evident in the work of health economists, and have implications for androcentric bias in the sub-discipline. The implications of these assumptions are investigated for one of the major areas of work in health economics - that of economic evaluation of health care interventions.Feminist thoery, health economics

What determines providers' stated preference for the treatment of uncomplicated malaria?

As agents for their patients, providers often make treatment decisions on behalf of patients, and their choices can affect health outcomes. However, providers operate within a network of relationships and are agents not only for their patients, but also other health sector actors, such as their employer, the Ministry of Health, and pharmaceutical suppliers. Providers' stated preferences for the treatment of uncomplicated malaria were examined to determine what factors predict their choice of treatment in the absence of information and institutional constraints, such as the stock of medicines or the patient's ability to pay. 518 providers working at non-profit health facilities and for-profit pharmacies and drug stores in Yaoundé and Bamenda in Cameroon and in Enugu State in Nigeria were surveyed between July and December 2009 to elicit the antimalarial they prefer to supply for uncomplicated malaria. Multilevel modelling was used to determine the effect of financial and non-financial incentives on their preference, while controlling for information and institutional constraints, and accounting for the clustering of providers within facilities and geographic areas. 69% of providers stated a preference for artemisinin-combination therapy (ACT), which is the recommended treatment for uncomplicated malaria in Cameroon and Nigeria. A preference for ACT was significantly associated with working at a for-profit facility, reporting that patients prefer ACT, and working at facilities that obtain antimalarials from drug company representatives. Preferences were similar among colleagues within a facility, and among providers working in the same locality. Knowing the government recommends ACT was a significant predictor, though having access to clinical guidelines was not sufficient. Providers are agents serving multiple principals and their preferences over alternative antimalarials were influenced by patients, drug company representatives, and other providers working at the same facility and in the local area. Efforts to disseminate drug policy should target the full range of actors involved in supplying drugs, including providers, employers, suppliers and local communities

Measuring inequalities in the distribution of the Fiji health workforce

Background: Despite the centrality of health personnel to the health of the population, the planning, production and management of human resources for health remains underdeveloped in many low- and middle-income countries (LMICs). In addition to the general shortage of health workers, there are significant inequalities in the distribution of health workers within LMICs. This is especially true for countries like Fiji, which face major challenges in distributing its health workforce across many inhabited islands. Methods: In this study, we describe and measure health worker distributional inequalities in Fiji, using data from the 2007 Population Census, and Ministry of Health records of crude death rates and health workforce personnel. We adopt methods from the economics literature including the Lorenz Curve/Gini Coefficient and Theil Index to measure the extent and drivers of inequality in the distribution of health workers at the sub-national level in Fiji for three categories of health workers: doctors, nurses, and all health workers (doctors, nurses, dentists and health support staff). Population size and crude death rates are used as proxies for health care needs. Results: There are greater inequalities in the densities of health workers at the provincial level, compared to the divisional level in Fiji – six of the 15 provinces fall short of the recommended threshold of 2.3 health workers per 1,000 people. The estimated decile ratios, Gini co-efficient and Thiel index point to inequalities at the provincial level in Fiji, mainly with respect to the distribution of doctors; however these inequalities are relatively small. Conclusion: While populations with lower mortality tend to have a slightly greater share of health workers, the overall distribution of health workers on the basis of need is more equitable in Fiji than for many other LMICs. The overall shortage of health workers could be addressed by creating new cadres of health workers; employing increasing numbers of foreign doctors, including specialists; and increasing funding for health worker training, as already demonstrated by the Fiji government. Close monitoring of the equitable distribution of additional health workers in the future is critical

Engaging the private sector to improve antimicrobial use in the community

Antimicrobial resistance (AMR) is one of the world’s most pressing public health threats. It increases the cost of health care through longer duration of illness and hospital stays, additional tests, and the need for more expensive drugs.AMR refers to the ability of a microorganism to stop an antimicrobial (such as an antibiotic, antiviral or antimalarial) from working against it. As a consequence of AMR, standard treatments become ineffective, and infections persist and may spread to others. The impact of AMR is far-reaching and equates to the situation before the discovery of antibiotics, when even small infections were difficult, or very often impossible to treat, and medical procedures too risky to perform due to the potential of untreatable infection.</jats:p

Cost-effectiveness analysis of insecticide-treated net distribution as part of the Togo Integrated Child Health Campaign

BACKGROUND: To evaluate the cost-effectiveness of the first nationwide delivery of long-lasting insecticide-treated nets (LLITNs) as part of the 2004 measles vaccination campaign in Togo to all children between nine months and five years. METHODS: An incremental approach was used to calculate the economic costs and effects from a provider perspective. Effectiveness was estimated in terms of malaria cases averted, deaths averted and Disability-Adjusted Life Years (DALYs) averted. Malaria cases were modelled using regional estimates. Programme and treatment costs were derived through reviews of financial records and interviews with key stakeholders. Uncertain variables were subjected to a univariate sensitivity analysis. RESULTS: Assuming equal attribution of shared costs between the LLITN distribution and the measles vaccination, the net costs per LLITN distributed were 4.41 USD when saved treatment costs were taken into account. Assuming a constant utilization of LLITNs by the target group over three years, 1.2 million cases could be prevented at a net cost per case averted of 3.26 USD. The net costs were 635 USD per death averted and 16.39 USD per DALY averted, respectively. CONCLUSION: The costs per case, death and DALY averted are well within commonly agreed benchmarks set by other malaria prevention studies. Varying transmission levels are shown to have a significant impact on cost-effectiveness ratios. Results also suggest that substantial efficiency gains may be derived from the joint delivery of vaccination campaigns and malaria interventions

The impact of long-lasting microbial larvicides in reducing malaria transmission and clinical malaria incidence: study protocol for a cluster randomized controlled trial.

BACKGROUND: The massive scale-up of insecticide-treated nets (ITNs) and indoor residual spraying (IRS) has led to a substantial increase in malaria vector insecticide resistance as well as in increased outdoor transmission, both of which hamper the effectiveness and efficiency of ITN and IRS. Long-lasting microbial larvicide can be a cost-effective new supplemental intervention tool for malaria control. METHODS/DESIGN: We will implement the long-lasting microbial larvicide intervention in 28 clusters in two counties in western Kenya. We will test FourStar controlled release larvicide (6 % by weight Bacillus thuringiensis israelensis and 1 % Bacillus sphaerius) by applying FourStar controlled release granule formulation, 90-day briquettes, and 180-day briquettes in different habitat types. The primary endpoint is clinical malaria incidence rate and the secondary endpoint is malaria vector abundance and transmission intensity. The intervention will be conducted as a two-step approach. First, we will conduct a four-cluster trial (two clusters per county, with one of the two clusters randomly assigned to the intervention arm) to optimize the larvicide application scheme. Second, we will conduct an open-label, cluster-randomized trial to evaluate the effectiveness and cost-effectiveness of the larvicide. Fourteen clusters in each county will be assigned to intervention (treatment) or no intervention (control) by a block randomization on the basis of clinical malaria incidence, vector density, and human population size per site. We will treat each treatment cluster with larvicide for three rounds at 4-month intervals, followed by no treatment for the following 8 months. Next, we will switch the control and treatment sites. The former control sites will receive three rounds of larvicide treatment at appropriate time intervals, and former treatment sites will receive no larvicide. We will monitor indoor and outdoor vector abundance using CO2-baited CDC light traps equipped with collection bottle rotators. Clinical malaria data will be aggregated from government-run malaria treatment centers. DISCUSSION: Since current first-line vector intervention methods do not target outdoor transmission and will select for higher insecticide resistance, new methods beyond bed nets and IRS should be considered. Long-lasting microbial larviciding represents a promising new tool that can target both indoor and outdoor transmission and alleviate the problem of pyrethroid resistance. It also has the potential to diminish costs by reducing larvicide reapplications. If successful, it could revolutionize malaria vector control in Africa, just as long-lasting bed nets have done. TRIAL REGISTRATION: U.S. National Institute of Health, study ID NCT02392832 . Registered on 3 February 2015

A qualitative study on health workers' and community members' perceived sources, role of information and communication on malaria treatment, prevention and control in southeast Nigeria.

BACKGROUND: It has been widely acknowledged that well-planned and executed communication programmes can contribute to achieving malaria prevention and treatment goals. This however requires a good understanding of current sources and roles of information used by both health workers and communities. The study aimed at determining health workers' and community members' sources, value and use of information on malaria prevention and treatment in Nigeria. METHODS: Qualitative data was collected from six selected communities (three urban and three rural) in Enugu state, southeast Nigeria. A total of 18 Focus Group Discussions (FGDs) with 179 community members and 26 in-depth interviews (IDIs) with health workers in public and private health facilities were used to collect data on where people receive treatment for malaria and access information on malaria. The FGDS and IDIs also provided data on the values, uses and effects of information and communication on malaria treatment seeking and provision of services. RESULTS: The findings revealed that the major sources of information on malaria for health workers and community members were advertisements in the mass media, workshops and seminars organized by donor agencies, facility supervision, posters, other health workers, television and radio adverts. Community involvement in the design and delivery of information on malaria control was seen as a strong strategy for improving both consumer and provider knowledge. Information from the different sources catalyzed appropriate provision and consumption of malaria treatment amongst health workers and community members. CONCLUSION: Health workers and consumers receive information on malaria prevention and treatment from multiple sources of communication and information, which they find useful. Harnessing these information sources to encourage consistent and accurate messages around malaria prevention and treatment is a necessary first step in the design and implementation of malaria communication and behaviour change interventions and ultimately for the sustained control of malaria