Governance Diaries: An Approach to Governance Research from the Ground Up

Research on empowerment and accountability tends to focus on collective action and its potential for empowering citizens undertaking the action and on achieving state accountability. In fragile, conflict and violence-affected settings (FCVAS) collective action is rare and risky. So how do citizens, particularly the chronically poor and most marginalised, interact and make claims on the different public authorities that exist in these settings, and how do these interactions contribute to citizens’ sense of empowerment and accountability? Given the current agenda of ‘leave no one behind’, an understanding of how such populations interact with public authorities to meet their governance needs can help identify the constraints to achieving development for all in these challenging settings. We developed ‘governance diaries,’ a cross between a panel survey and multi-sited ethnographies, as an iterative approach to capture their experiences around governance issues over time. We explain here how this approach works, and the challenges and opportunities it offers for research.UK Department for International Developmen

Celebrating Adaptive Delivery: A View from the Frontline in Myanmar

The conversation on adaptive management has grown fast amongst development actors. These conversations often focus on designing, commissioning, and managing large-scale development programmes. Exactly how this impacts the frontline, the implementers, and day-to-day project delivery is still being debated. Yet, perspectives drawn directly from practice are often largely missing within these debates. This paper is written by two development practitioners. Through this paper, we reflect on the difference between adaptive management and adaptive delivery, and how this interacts with risk and aid accountability, particularly in contexts of fragility. Drawing on examples of Oxfam in Myanmar work and our personal insights in relation to delivering programming across humanitarian, peace-building, and development, we suggest that in complex, conflict-affected, and highly political environments adaptive delivery already happens far more regularly than is currently recognised, as a necessity to get activities delivered. However, it happens despite the system, not because of it, and is therefore often hidden and carried out ‘under the radar’ rather than celebrated as a success in difficult environments. This paper was written in 2019, before the military seized control of Myanmar in February 2021. Whilst it draws on examples from pre-2021 Myanmar to illustrate real life cases, it is a contribution to a broader global debate on adaptive management in practice, specifically in fragile contexts. This is not specifically aimed at practitioners working in Myanmar at present, who are now working in a protracted crisis. This paper makes tangible recommendations on steps that donors, international non-governmental organisations, local staff, and partners could take to promote a system of encouraging and celebrating adaptability in programme delivery in fragile contexts.Foreign, Commonwealth & Development Offic

Mothers’ accounts of the impact of being in nature on postnatal wellbeing: a focus group study

Background The postnatal period is a vulnerable time for mothers to experience stress and mental health difficulties. There is increasing evidence that spending time in nature is beneficial for wellbeing. Nature-based interventions have been developed to support mental health, but not specifically tailored for mothers during the postnatal period. Understanding mothers’ views and experiences of nature would help determine the suitability for and potential impact of such interventions on postnatal wellbeing. Aims To explore mothers’ views on the impact of spending time in nature on their postnatal mental wellbeing. Methods Focus groups were held with mothers of young children (under five), including mothers from migrant and refugee communities, mothers living with mental health difficulties, and disabled mothers. Data were analysed using reflexive thematic analysis. Results Four focus groups were held, with a total of 30 participants. Six themes were developed: (1) mothers’ experiences of what constitutes ‘nature’; (2) sensing nature improves wellbeing; (3) natural spaces facilitate human connection; (4) nature provides escape and relief from daily indoor stressors; (5) nature allows new perspectives; and (6) mothers face a variety of environmental, practical, psychological, physical, socioeconomic, and cultural barriers to spending time in nature during the postnatal period. Conclusions Mothers report significant benefits to their postnatal wellbeing when spending time in nature. Further research is warranted to understand whether nature-based interventions have the potential to support postnatal wellbeing, socially, mentally, and physically

Governance Diaries: An Approach to Researching Marginalized People’s Lived Experiences in Difficult Settings

How do chronically poor and marginalized citizens interact with and make claims to the different public authorities that exist in fragile, conflict and violence-affected contexts? In other words, how does governance from below look like in difficult settings? Given the centrality of the ‘leave no one behind’ agenda, an understanding of how such populations meet their governance needs can help identify the constraints to achieving development for all in these challenging settings. We wanted to research these questions comparatively, to see if there were common features of response in different contexts, with the presence of various kinds of non-state actors, diverse histories of colonialism and authoritarianism, and widely different social norms. In this article we describe the governance diaries approach, an iterative alternative to large-n surveys and multi-sited ethnographies we developed in the process of answering these questions. Governance diaries, working as a qualitative panel data, are a suitable approach for researching complex behavior that changes over time as large-n surveys are insufficiently dynamic to trace the processes behind change (lacking sensitivity) and ethnographic studies often have limited generalizability (lacking comparability). We describe here how this approach works and the challenges and opportunities it offers for research

Clinical effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: the CoBalT randomised controlled trial

Background: Only one-third of patients with depression respond fully to treatment with antidepressant medication. However, there is little robust evidence to guide the management of those whose symptoms are 'treatment resistant'.<p></p> Objective: The CoBalT trial examined the clinical effectiveness and cost-effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment-resistant depression (TRD) compared with usual care alone.<p></p> Design: Pragmatic, multicentre individually randomised controlled trial with follow-up at 3, 6, 9 and 12 months. A subset took part in a qualitative study investigating views and experiences of CBT, reasons for completing/not completing therapy, and usual care for TRD.<p></p> Setting: General practices in Bristol, Exeter and Glasgow, and surrounding areas.<p></p> Participants: Patients aged 18-75 years who had TRD [on antidepressants for 6 weeks, had adhered to medication, Beck Depression Inventory, 2nd version (BDI-II) score of 14 and fulfilled the International Classification of Diseases and Related Health Problems, Tenth edition criteria for depression]. Individuals were excluded who (1) had bipolar disorder/psychosis or major alcohol/substance abuse problems; (2) were unable to complete the questionnaires; or (3) were pregnant, as were those currently receiving CBT/other psychotherapy/secondary care for depression, or who had received CBT in the past 3 years.<p></p> Interventions: Participants were randomised, using a computer-generated code, to usual care or CBT (12-18 sessions) in addition to usual care.<p></p> Main outcome measures: The primary outcome was 'response', defined as 50% reduction in depressive symptoms (BDI-II score) at 6 months compared with baseline. Secondary outcomes included BDI-II score as a continuous variable, remission of symptoms (BDI-II score of < 10), quality of life, anxiety and antidepressant use at 6 and 12 months. Data on health and social care use, personal costs, and time off work were collected at 6 and 12 months. Costs from these three perspectives were reported using a cost-consequence analysis. A cost-utility analysis compared health and social care costs with quality adjusted life-years.<p></p> Results: A total of 469 patients were randomised (intervention: n = 234; usual care: n = 235), with 422 participants (90%) and 396 (84%) followed up at 6 and 12 months. Ninety-five participants (46.1%) in the intervention group met criteria for 'response' at 6 months compared with 46 (21.6%) in the usual-care group {odds ratio [OR] 3.26 [95% confidence interval (CI) 2.10 to 5.06], p < 0.001}. In repeated measures analyses using data from 6 and 12 months, the OR for 'response' was 2.89 (95% CI 2.03 to 4.10, p < 0.001) and for a secondary 'remission' outcome (BDI-II score of < 10) 2.74 (95% CI 1.82 to 4.13, p < 0.001). The mean cost of CBT per participant was £910, the incremental health and social care cost £850, the incremental QALY gain 0.057 and incremental cost-effectiveness ratio £14,911. Forty participants were interviewed. Patients described CBT as challenging but helping them to manage their depression; listed social, emotional and practical reasons for not completing treatment; and described usual care as mainly taking medication.<p></p> Conclusions: Among patients who have not responded to antidepressants, augmenting usual care with CBT is effective in reducing depressive symptoms, and these effects, including outcomes reflecting remission, are maintained over 12 months. The intervention was cost-effective based on the National Institute for Health and Care Excellence threshold. Patients may experience CBT as difficult but effective. Further research should evaluate long-term effectiveness, as this would have major implications for the recommended treatment of depression.<p></p&gt

Bimodal distribution and set point HBV DNA viral loads in chronic infection:retrospective analysis of cohorts from the UK and South Africa

CITATION: Downs, L. O. 2020. Bimodal distribution and set point HBV DNA viral loads in chronic infection : retrospective analysis of cohorts from the UK and South Africa. Wellcome Open Research, 14(5):113, doi: 10.12688/wellcomeopenres.15941.2.The original publication is available at: https://pubmed.ncbi.nlm.nih.govENGLISH ABSTRACT: Hepatitis B virus (HBV) viral load (VL) is used as a biomarker to assess risk of disease progression, and to determine eligibility for treatment. While there is a well recognised association between VL and the expression of the viral e-antigen protein, the distributions of VL at a population level are not well described. We here present cross-sectional, observational HBV VL data from two large population cohorts in the UK and in South Africa, demonstrating a consistent bimodal distribution. The right skewed distribution and low median viral loads are different from the left-skew and higher viraemia in seen in HIV and hepatitis C virus (HCV) cohorts in the same settings. Using longitudinal data, we present evidence for a stable 'set-point' VL in peripheral blood during chronic HBV infection. These results are important to underpin improved understanding of HBV biology, to inform approaches to viral sequencing, and to plan public health interventions.Publisher's versio

Bimodal distribution and set point HBV DNA viral loads in chronic infection:retrospective analysis of cohorts from the UK and South Africa

CITATION: Downs, L. O. 2020. Bimodal distribution and set point HBV DNA viral loads in chronic infection : retrospective analysis of cohorts from the UK and South Africa. Wellcome Open Research, 14(5):113, doi: 10.12688/wellcomeopenres.15941.2.The original publication is available at: https://pubmed.ncbi.nlm.nih.govENGLISH ABSTRACT: Hepatitis B virus (HBV) viral load (VL) is used as a biomarker to assess risk of disease progression, and to determine eligibility for treatment. While there is a well recognised association between VL and the expression of the viral e-antigen protein, the distributions of VL at a population level are not well described. We here present cross-sectional, observational HBV VL data from two large population cohorts in the UK and in South Africa, demonstrating a consistent bimodal distribution. The right skewed distribution and low median viral loads are different from the left-skew and higher viraemia in seen in HIV and hepatitis C virus (HCV) cohorts in the same settings. Using longitudinal data, we present evidence for a stable 'set-point' VL in peripheral blood during chronic HBV infection. These results are important to underpin improved understanding of HBV biology, to inform approaches to viral sequencing, and to plan public health interventions.Publisher's versio

Management of treatment-resistant depression in primary care:a mixed-methods study

Background: Non-response to antidepressant medication is common in primary care. Little is known about how GPs manage patients with depression that does not respond to medication. Aim: To describe usual care for primary care patients with treatment-resistant depression (TRD). Design and setting: Mixed-methods study using data from a UK primary care multicentre randomised controlled trial. Method: In total, 235 patients with TRD randomised to continue with usual GP care were followed up at 3-month intervals for a year. Self-report data were collected on antidepressant medication, number of GP visits, and other treatments received. In addition, 14 semi-structured face-to-face interviews were conducted with a purposive sample after the 6-month follow-up and analysed thematically. Results: Most patients continued on the same dose of a single antidepressant between baseline and 3 months (n = 147/186 at 3 months, 79% (95% confidence interval [CI] = 73 to 85%)). Figures were similar for later follow-ups (for example, 9–12 months: 72% (95% CI = 63 to 79%). Medication changes (increasing dose; switching to a different antidepressant; adding a second antidepressant) were uncommon. Participants described usual care mainly as taking antidepressants, with consultations focused on other (physical) health concerns. Few accessed other treatments or were referred to secondary care. Conclusion: Usual care in patients with TRD mainly entailed taking antidepressants, and medication changes were uncommon. The high prevalence of physical and psychological comorbidity means that, when these patients consult, their depression may not be discussed. Strategies are needed to ensure the active management of this large group of patients whose depression does not respond to antidepressant medication

Rasgrp1 mutation increases naïve T-cell CD44 expression and drives mTOR-dependent accumulation of Helios+ T cells and autoantibodies

Missense variants are a major source of human genetic variation. Here we analyze a new mouse missense variant, Rasgrp1Anaef, with an ENU-mutated EF hand in the Rasgrp1 Ras guanine nucleotide exchange factor. Rasgrp1Anaef mice exhibit anti-nuclear autoantibodies and gradually accumulate a CD44hi Helios+ PD-1+ CD4+ T cell population that is dependent on B cells. Despite reduced Rasgrp1-Ras-ERK activation in vitro, thymocyte selection in Rasgrp1Anaef is mostly normal in vivo, although CD44 is overexpressed on naïve thymocytes and T cells in a T-cell-autonomous manner. We identify CD44 expression as a sensitive reporter of tonic mTOR-S6 kinase signaling through a novel mouse strain, chino, with a reduction-of-function mutation in Mtor. Elevated tonic mTOR-S6 signaling occurs in Rasgrp1Anaef naïve CD4+ T cells. CD44 expression, CD4+ T cell subset ratios and serum autoantibodies all returned to normal in Rasgrp1AnaefMtorchino double-mutant mice, demonstrating that increased mTOR activity is essential for the Rasgrp1Anaef T cell dysregulation